- 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
- $2,944.50 / $4,888.76 / $7,668.26
| Professional | | $2,944.50 | $4,888.76 | $7,668.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,264.60 / $6,894.07 / $9,066.84
| Facility | | $4,264.60 | $6,894.07 | $9,066.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,561.18 / $6,894.07 / $8,902.94
| Facility | | $4,561.18 | $6,894.07 | $8,902.94 |
- 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 |