- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $6,066.00 / $11,100.08
| Facility | | $4,277.00 | $6,066.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.93 / $2,765.37 / $6,537.89
| Professional | | $1,755.93 | $2,765.37 | $6,537.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,553.89 / $4,316.07 / $11,688.00
| Facility | | $2,553.89 | $4,316.07 | $11,688.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,266.81 / $4,194.29 / $5,359.74
| Facility | | $3,266.81 | $4,194.29 | $5,359.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,542.00 / $12,871.00 / $16,293.00
| Facility | | $9,542.00 | $12,871.00 | $16,293.00 |