- 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
- $1,017.35 / $1,439.70 / $3,589.07
| Professional | | $1,017.35 | $1,439.70 | $3,589.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,662.00 / $3,092.31 / $13,250.95
| Facility | | $1,662.00 | $3,092.31 | $13,250.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.00 / $3,389.08 / $5,256.68
| Facility | | $1,932.00 | $3,389.08 | $5,256.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $13,238.00
| Facility | | $7,221.00 | $8,060.00 | $13,238.00 |