- 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
- $1,080.28 / $2,048.38 / $3,896.61
| Professional | | $1,080.28 | $2,048.38 | $3,896.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,163.58 / $2,958.62 / $6,608.00
| Facility | | $2,163.58 | $2,958.62 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.75 / $2,748.92 / $3,561.27
| Facility | | $1,823.75 | $2,748.92 | $3,561.27 |
- 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 |