- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,960.00 / $11,611.47
| Facility | | $4,964.00 | $6,960.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,685.83 / $2,803.94 / $4,684.83
| Professional | | $1,685.83 | $2,803.94 | $4,684.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.93 / $3,994.16 / $7,123.00
| Facility | | $2,626.93 | $3,994.16 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,764.04 / $3,994.16 / $5,453.56
| Facility | | $2,764.04 | $3,994.16 | $5,453.56 |
- 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 |