- 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
- $1,098.10 / $1,724.35 / $2,914.78
| Professional | | $1,098.10 | $1,724.35 | $2,914.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,511.56 / $2,593.15 / $6,608.00
| Facility | | $1,511.56 | $2,593.15 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.72 / $2,593.15 / $3,407.02
| Facility | | $1,758.72 | $2,593.15 | $3,407.02 |
- 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 |