- 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
- $1,094.89 / $1,880.69 / $3,527.45
| Professional | | $1,094.89 | $1,880.69 | $3,527.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.67 / $2,874.63 / $27,984.26
| Facility | | $1,845.67 | $2,874.63 | $27,984.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,150.27 / $2,874.63 / $27,984.26
| Facility | | $2,150.27 | $2,874.63 | $27,984.26 |
- 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 |