- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.00 / $7,090.00 / $11,611.47
| Facility | | $5,091.00 | $7,090.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.09 / $2,504.59 / $5,591.44
| Professional | | $1,631.09 | $2,504.59 | $5,591.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,102.06 / $4,438.18 / $28,675.35
| Facility | | $2,102.06 | $4,438.18 | $28,675.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,416.54 / $4,677.99 / $24,582.94
| Facility | | $3,416.54 | $4,677.99 | $24,582.94 |
- 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 |