- 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
- $1,490.05 / $2,354.59 / $5,014.64
| Professional | | $1,490.05 | $2,354.59 | $5,014.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,956.60 / $3,188.59 / $4,847.81
| Facility | | $1,956.60 | $3,188.59 | $4,847.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,383.28 / $3,524.72 / $4,847.81
| Facility | | $2,383.28 | $3,524.72 | $4,847.81 |
- 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 |