- 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
- $705.48 / $1,105.91 / $2,735.36
| Professional | | $705.48 | $1,105.91 | $2,735.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.33 / $1,940.69 / $7,305.00
| Facility | | $1,148.33 | $1,940.69 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,155.84 / $1,665.92 / $2,257.36
| Facility | | $1,155.84 | $1,665.92 | $2,257.36 |
- 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 |