- 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
- $1,442.59 / $2,258.53 / $4,956.27
| Professional | | $1,442.59 | $2,258.53 | $4,956.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.53 / $3,229.56 / $4,670.77
| Facility | | $1,897.53 | $3,229.56 | $4,670.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,353.11 / $3,415.55 / $4,670.77
| Facility | | $2,353.11 | $3,415.55 | $4,670.77 |
- 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 |