- 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
- $2,018.40 / $3,273.36 / $5,902.77
| Professional | | $2,018.40 | $3,273.36 | $5,902.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,295.63 / $4,110.10 / $6,328.04
| Facility | | $2,295.63 | $4,110.10 | $6,328.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,356.24 / $4,916.99 / $6,605.88
| Facility | | $3,356.24 | $4,916.99 | $6,605.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,966.00 / $6,110.41 / $7,407.10
| Facility | | $1,966.00 | $6,110.41 | $7,407.10 |