- 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
- $1,115.89 / $1,883.56 / $3,479.84
| Professional | | $1,115.89 | $1,883.56 | $3,479.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,168.85 / $2,953.55 / $7,305.00
| Facility | | $2,168.85 | $2,953.55 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.51 / $2,747.71 / $3,557.82
| Facility | | $1,861.51 | $2,747.71 | $3,557.82 |
- 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 |