- 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
- $2,613.12 / $4,068.25 / $8,239.14
| Professional | | $2,613.12 | $4,068.25 | $8,239.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,396.00 / $5,183.67 / $7,856.00
| Facility | | $3,396.00 | $5,183.67 | $7,856.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,248.76 / $6,168.80 / $8,809.86
| Facility | | $4,248.76 | $6,168.80 | $8,809.86 |
- 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 |