- 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
- $1,121.60 / $1,583.86 / $3,429.59
| Professional | | $1,121.60 | $1,583.86 | $3,429.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.00 / $3,436.46 / $11,732.00
| Facility | | $1,862.00 | $3,436.46 | $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
- $6,354.00 / $8,868.00 / $17,495.71
| Facility | | $6,354.00 | $8,868.00 | $17,495.71 |