- 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
- $1,741.81 / $2,891.46 / $4,663.17
| Professional | | $1,741.81 | $2,891.46 | $4,663.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,950.00 / $4,265.62 / $6,608.00
| Facility | | $2,950.00 | $4,265.62 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,678.10 / $4,009.37 / $5,243.98
| Facility | | $2,678.10 | $4,009.37 | $5,243.98 |
- 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 |