- 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
- $1,147.56 / $1,891.45 / $3,216.76
| Professional | | $1,147.56 | $1,891.45 | $3,216.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,956.13 / $3,434.58 / $14,396.24
| Facility | | $1,956.13 | $3,434.58 | $14,396.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,010.00 / $3,684.60 / $5,383.60
| Facility | | $2,010.00 | $3,684.60 | $5,383.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,523.00 / $11,869.99
| Facility | | $7,221.00 | $8,523.00 | $11,869.99 |