- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,955.00 / $11,668.15
| Facility | | $4,964.00 | $6,955.00 | $11,668.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.75 / $2,717.18 / $5,091.84
| Professional | | $1,708.75 | $2,717.18 | $5,091.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,213.42 / $4,098.79 / $7,305.00
| Facility | | $2,213.42 | $4,098.79 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,321.27 / $4,173.18 / $5,642.77
| Facility | | $3,321.27 | $4,173.18 | $5,642.77 |
- 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 |