- 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
- $1,286.28 / $2,035.76 / $3,869.77
| Professional | | $1,286.28 | $2,035.76 | $3,869.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,110.34 / $3,265.21 / $7,305.00
| Facility | | $2,110.34 | $3,265.21 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,112.30 / $3,003.62 / $4,038.36
| Facility | | $2,112.30 | $3,003.62 | $4,038.36 |
- 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 |