- 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
- $788.37 / $1,236.24 / $2,885.12
| Professional | | $788.37 | $1,236.24 | $2,885.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.84 / $1,966.00 / $7,305.00
| Facility | | $1,029.84 | $1,966.00 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,251.05 / $1,869.08 / $2,422.12
| Facility | | $1,251.05 | $1,869.08 | $2,422.12 |
- 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 |