- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $8,042.03
| Facility | | $3,496.00 | $4,964.00 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.29 / $2,072.98 / $4,927.08
| Professional | | $1,333.29 | $2,072.98 | $4,927.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.53 / $3,175.38 / $6,608.00
| Facility | | $1,675.53 | $3,175.38 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,802.85 / $2,692.86 / $3,793.90
| Facility | | $1,802.85 | $2,692.86 | $3,793.90 |
- 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 |