- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,066.00 / $7,119.04
| Facility | | $4,964.00 | $6,066.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.33 / $1,930.22 / $4,361.41
| Professional | | $1,243.33 | $1,930.22 | $4,361.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,536.32 / $3,034.97 / $11,732.00
| Facility | | $1,536.32 | $3,034.97 | $11,732.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.67 / $3,000.71 / $4,176.95
| Facility | | $2,151.67 | $3,000.71 | $4,176.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $7,487.00 / $11,732.00
| Facility | | $1,770.00 | $7,487.00 | $11,732.00 |