- 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
- $1,861.35 / $3,089.19 / $5,951.42
| Professional | | $1,861.35 | $3,089.19 | $5,951.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,468.96 / $4,385.88 / $5,773.81
| Facility | | $2,468.96 | $4,385.88 | $5,773.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,116.88 / $4,404.62 / $6,231.98
| Facility | | $3,116.88 | $4,404.62 | $6,231.98 |
- 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 |