- 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
- $1,125.46 / $1,589.27 / $4,071.36
| Professional | | $1,125.46 | $1,589.27 | $4,071.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.00 / $3,455.33 / $13,250.95
| Facility | | $1,875.00 | $3,455.33 | $13,250.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.00 / $3,490.48 / $5,256.68
| Facility | | $1,932.00 | $3,490.48 | $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 |