- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,960.00 / $11,611.47
| Facility | | $4,964.00 | $6,960.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.59 / $2,676.75 / $4,511.51
| Professional | | $1,541.59 | $2,676.75 | $4,511.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,621.32 / $3,808.05 / $6,316.20
| Facility | | $2,621.32 | $3,808.05 | $6,316.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,522.03 / $3,796.49 / $4,965.55
| Facility | | $2,522.03 | $3,796.49 | $4,965.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |