- 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
- $651.23 / $1,071.28 / $1,794.08
| Professional | | $651.23 | $1,071.28 | $1,794.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,144.65 / $1,698.45 / $5,847.00
| Facility | | $1,144.65 | $1,698.45 | $5,847.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,050.02 / $1,547.30 / $2,081.21
| Facility | | $1,050.02 | $1,547.30 | $2,081.21 |
- 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 |