- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,012.00 / $6,298.62 / $10,255.42
| Facility | | $5,012.00 | $6,298.62 | $10,255.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.77 / $2,402.69 / $3,060.84
| Professional | | $1,534.77 | $2,402.69 | $3,060.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,692.63 / $3,566.13 / $8,604.00
| Facility | | $1,692.63 | $3,566.13 | $8,604.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,869.62 / $3,679.02 / $4,623.71
| Facility | | $2,869.62 | $3,679.02 | $4,623.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |