- 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
- $1,297.22 / $2,121.84 / $4,619.92
| Professional | | $1,297.22 | $2,121.84 | $4,619.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,740.24 / $2,850.80 / $4,663.00
| Facility | | $1,740.24 | $2,850.80 | $4,663.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,170.94 / $3,132.43 / $4,409.09
| Facility | | $2,170.94 | $3,132.43 | $4,409.09 |
- 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 |