- 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
- $705.89 / $996.80 / $1,990.38
| Professional | | $705.89 | $996.80 | $1,990.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,269.16 / $2,216.86 / $6,945.09
| Facility | | $1,269.16 | $2,216.86 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,472.55 / $1,948.53 / $2,428.62
| Facility | | $1,472.55 | $1,948.53 | $2,428.62 |
- 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 |