- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,837.40 / $6,907.00 / $12,472.19
| Facility | | $5,837.40 | $6,907.00 | $12,472.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.00 / $1,645.00 / $4,573.00
| Professional | | $1,581.00 | $1,645.00 | $4,573.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.00 / $2,151.00 / $2,151.00
| Facility | | $2,151.00 | $2,151.00 | $2,151.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,371.73 / $11,970.55 / $29,792.60
| Facility | | $5,371.73 | $11,970.55 | $29,792.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.23 / $1,613.23 / $1,613.23
| Professional | | $1,613.23 | $1,613.23 | $1,613.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,663.00 / $2,530.00 / $2,530.00
| Facility | | $1,663.00 | $2,530.00 | $2,530.00 |