- 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
- $1,930.83 / $3,000.94 / $5,174.83
| Professional | | $1,930.83 | $3,000.94 | $5,174.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.94 / $4,749.02 / $6,608.00
| Facility | | $2,608.94 | $4,749.02 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,183.77 / $4,628.05 / $6,277.36
| Facility | | $3,183.77 | $4,628.05 | $6,277.36 |
- 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 |