- 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
- $1,897.69 / $2,928.19 / $6,204.37
| Professional | | $1,897.69 | $2,928.19 | $6,204.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,453.48 / $4,399.14 / $5,832.43
| Facility | | $2,453.48 | $4,399.14 | $5,832.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,145.72 / $4,496.33 / $6,158.17
| Facility | | $3,145.72 | $4,496.33 | $6,158.17 |
- 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 |