- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $7,120.36
| Facility | | $4,146.00 | $5,091.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.27 / $1,928.85 / $4,156.08
| Professional | | $1,103.27 | $1,928.85 | $4,156.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.72 / $3,006.36 / $6,674.81
| Facility | | $1,772.72 | $3,006.36 | $6,674.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,464.31 / $3,037.10 / $7,164.29
| Facility | | $2,464.31 | $3,037.10 | $7,164.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |