- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,955.00 / $11,668.15
| Facility | | $4,964.00 | $6,955.00 | $11,668.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,723.35 / $3,330.56
| Professional | | $1,096.48 | $1,723.35 | $3,330.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,374.14 / $2,643.92 / $7,305.00
| Facility | | $1,374.14 | $2,643.92 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,063.34 / $2,591.85 / $3,535.20
| Facility | | $2,063.34 | $2,591.85 | $3,535.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,854.53 / $7,305.00
| Facility | | $2,126.00 | $5,854.53 | $7,305.00 |