- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.00 / $7,090.00 / $11,611.47
| Facility | | $5,091.00 | $7,090.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.56 / $1,579.56 / $3,618.42
| Professional | | $1,117.56 | $1,579.56 | $3,618.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,973.38 / $3,432.88 / $11,732.00
| Facility | | $1,973.38 | $3,432.88 | $11,732.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.00 / $3,141.50 / $4,188.66
| Facility | | $1,932.00 | $3,141.50 | $4,188.66 |
- 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 |