- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,960.00 / $11,611.47
| Facility | | $4,964.00 | $6,960.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.48 / $1,847.88 / $3,044.47
| Professional | | $1,077.48 | $1,847.88 | $3,044.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,734.42 / $3,004.27 / $22,189.40
| Facility | | $1,734.42 | $3,004.27 | $22,189.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.10 / $2,570.66 / $3,553.98
| Facility | | $1,815.10 | $2,570.66 | $3,553.98 |
- 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 |