- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $5,549.00 / $11,100.08
| Facility | | $4,277.00 | $5,549.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.71 / $3,857.43 / $6,655.55
| Professional | | $2,084.71 | $3,857.43 | $6,655.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,879.76 / $6,030.52 / $7,818.88
| Facility | | $2,879.76 | $6,030.52 | $7,818.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,157.29 / $6,030.52 / $8,174.37
| Facility | | $4,157.29 | $6,030.52 | $8,174.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,305.00
| Facility | | $2,126.00 | $5,847.00 | $7,305.00 |