- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,073.80 / $4,897.79
| Facility | | $2,884.03 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,772.37 / $9,772.37
| Facility | | $6,025.60 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,772.37 / $9,772.37
| Professional | | $6,025.60 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,073.80 / $4,897.79
| Facility | | $2,884.03 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $10,000.00 / $21,379.62
| Facility | | $3,715.35 | $10,000.00 | $21,379.62 |