- 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
- $1,862.75 / $2,988.48 / $4,933.68
| Professional | | $1,862.75 | $2,988.48 | $4,933.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,146.67 / $4,691.30 / $7,305.00
| Facility | | $2,146.67 | $4,691.30 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,068.33 / $4,486.14 / $6,044.67
| Facility | | $3,068.33 | $4,486.14 | $6,044.67 |
- 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 |