- 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
- $1,251.82 / $2,105.92 / $3,520.07
| Professional | | $1,251.82 | $2,105.92 | $3,520.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,970.77 / $3,049.94 / $6,608.00
| Facility | | $1,970.77 | $3,049.94 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,058.91 / $2,965.28 / $4,066.39
| Facility | | $2,058.91 | $2,965.28 | $4,066.39 |
- 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 |