- 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
- $723.74 / $1,242.68 / $2,101.52
| Professional | | $723.74 | $1,242.68 | $2,101.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,307.00 / $2,176.17 / $8,328.70
| Facility | | $1,307.00 | $2,176.17 | $8,328.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,307.00 / $2,133.98 / $2,571.84
| Facility | | $1,307.00 | $2,133.98 | $2,571.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |