- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $2,138.00 / $6,434.70
| Facility | | $1,181.00 | $2,138.00 | $6,434.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.00 / $1,846.00 / $2,101.00
| Professional | | $1,846.00 | $1,846.00 | $2,101.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.93 / $5,300.93 / $6,361.12
| Facility | | $5,300.93 | $5,300.93 | $6,361.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,840.03 / $3,840.03 / $3,840.03
| Facility | | $3,840.03 | $3,840.03 | $3,840.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,957.00
| Facility | | $1,565.00 | $2,828.00 | $6,957.00 |