- 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
- $998.90 / $1,632.93 / $2,717.43
| Professional | | $998.90 | $1,632.93 | $2,717.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,663.21 / $2,422.67 / $6,608.00
| Facility | | $1,663.21 | $2,422.67 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,607.57 / $2,367.52 / $3,168.66
| Facility | | $1,607.57 | $2,367.52 | $3,168.66 |
- 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 |