- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,960.00 / $11,611.47
| Facility | | $4,964.00 | $6,960.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.64 / $2,388.30 / $4,459.89
| Professional | | $1,258.64 | $2,388.30 | $4,459.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,515.21 / $3,440.76 / $6,608.00
| Facility | | $2,515.21 | $3,440.76 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,123.71 / $3,199.89 / $4,141.08
| Facility | | $2,123.71 | $3,199.89 | $4,141.08 |
- 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 |