- 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
- $1,679.34 / $2,640.44 / $5,669.27
| Professional | | $1,679.34 | $2,640.44 | $5,669.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,214.53 / $3,827.55 / $5,287.62
| Facility | | $2,214.53 | $3,827.55 | $5,287.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,705.74 / $3,986.15 / $5,322.98
| Facility | | $2,705.74 | $3,986.15 | $5,322.98 |
- 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 |