- 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
- $505.18 / $839.46 / $1,287.99
| Professional | | $505.18 | $839.46 | $1,287.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $983.80 / $1,692.14 / $6,306.00
| Facility | | $983.80 | $1,692.14 | $6,306.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.79 / $1,614.54 / $2,052.00
| Facility | | $1,219.79 | $1,614.54 | $2,052.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |