- 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
- $1,665.91 / $2,652.24 / $5,477.47
| Professional | | $1,665.91 | $2,652.24 | $5,477.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,170.00 / $3,889.96 / $5,244.00
| Facility | | $2,170.00 | $3,889.96 | $5,244.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,792.60 / $3,943.94 / $5,611.10
| Facility | | $2,792.60 | $3,943.94 | $5,611.10 |
- 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 |