- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.00 / $2,606.75 / $7,114.74
| Professional | | $1,681.00 | $2,606.75 | $7,114.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,189.10 / $4,055.91 / $6,608.00
| Facility | | $2,189.10 | $4,055.91 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,909.28 / $3,263.74 / $4,776.72
| Facility | | $1,909.28 | $3,263.74 | $4,776.72 |
- 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 |