- 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
- $2,001.62 / $3,052.37 / $6,978.53
| Professional | | $2,001.62 | $3,052.37 | $6,978.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,462.46 / $4,154.64 / $6,265.50
| Facility | | $2,462.46 | $4,154.64 | $6,265.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,459.83 / $4,788.89 / $6,727.06
| Facility | | $3,459.83 | $4,788.89 | $6,727.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.00 / $5,847.00 / $7,856.00
| Facility | | $1,321.00 | $5,847.00 | $7,856.00 |