- 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
- $2,240.75 / $3,611.35 / $4,833.41
| Professional | | $2,240.75 | $3,611.35 | $4,833.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,739.55 / $5,733.85 / $10,463.00
| Facility | | $3,739.55 | $5,733.85 | $10,463.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,311.17 / $5,424.63 / $7,095.08
| Facility | | $4,311.17 | $5,424.63 | $7,095.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,542.00 / $12,871.00 / $16,293.00
| Facility | | $9,542.00 | $12,871.00 | $16,293.00 |