- 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
- $1,248.83 / $2,229.54 / $5,387.13
| Professional | | $1,248.83 | $2,229.54 | $5,387.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.34 / $3,032.87 / $5,988.00
| Facility | | $1,850.34 | $3,032.87 | $5,988.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,066.34 / $2,962.13 / $4,161.93
| Facility | | $2,066.34 | $2,962.13 | $4,161.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $5,327.00 / $8,342.00
| Facility | | $1,770.00 | $5,327.00 | $8,342.00 |