- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $5,549.00 / $11,100.08
| Facility | | $4,277.00 | $5,549.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.33 / $1,088.54 / $2,378.06
| Professional | | $694.33 | $1,088.54 | $2,378.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $928.68 / $1,799.21 / $7,123.00
| Facility | | $928.68 | $1,799.21 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.08 / $1,640.45 / $2,224.31
| Facility | | $1,137.08 | $1,640.45 | $2,224.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,305.00
| Facility | | $2,126.00 | $5,847.00 | $7,305.00 |