- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,012.00 / $6,405.00 / $10,255.42
| Facility | | $5,012.00 | $6,405.00 | $10,255.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.08 / $1,733.88 / $4,424.47
| Professional | | $1,138.08 | $1,733.88 | $4,424.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,405.24 / $2,582.96 / $15,086.34
| Facility | | $1,405.24 | $2,582.96 | $15,086.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.67 / $3,609.25 / $8,854.25
| Facility | | $2,155.67 | $3,609.25 | $8,854.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,723.00 / $9,673.00 / $14,242.22
| Facility | | $4,723.00 | $9,673.00 | $14,242.22 |