- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,066.00 / $7,119.04
| Facility | | $4,964.00 | $6,066.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.94 / $2,981.84 / $7,157.83
| Professional | | $1,956.94 | $2,981.84 | $7,157.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,684.14 / $4,684.71 / $6,144.92
| Facility | | $2,684.14 | $4,684.71 | $6,144.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,363.53 / $4,700.12 / $6,561.58
| Facility | | $3,363.53 | $4,700.12 | $6,561.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,950.00 / $5,732.00 / $8,342.00
| Facility | | $2,950.00 | $5,732.00 | $8,342.00 |