- 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
- $2,427.78 / $3,809.14 / $11,627.65
| Professional | | $2,427.78 | $3,809.14 | $11,627.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,950.00 / $4,786.92 / $7,161.84
| Facility | | $2,950.00 | $4,786.92 | $7,161.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.95 / $5,814.36 / $7,495.72
| Facility | | $3,813.95 | $5,814.36 | $7,495.72 |
- 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 |