- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,693.00 / $5,817.59 / $7,943.37
| Facility | | $4,693.00 | $5,817.59 | $7,943.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.83 / $2,175.08 / $5,153.63
| Professional | | $1,340.83 | $2,175.08 | $5,153.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,825.57 / $3,007.02 / $4,898.00
| Facility | | $1,825.57 | $3,007.02 | $4,898.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,154.17 / $3,171.74 / $4,492.53
| Facility | | $2,154.17 | $3,171.74 | $4,492.53 |
- 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 |