- 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
- $1,258.10 / $2,158.31 / $3,671.73
| Professional | | $1,258.10 | $2,158.31 | $3,671.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,031.54 / $3,809.55 / $14,396.24
| Facility | | $2,031.54 | $3,809.55 | $14,396.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,287.00 / $3,809.55 / $5,383.60
| Facility | | $2,287.00 | $3,809.55 | $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 |