- 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
- $1,242.35 / $2,002.58 / $2,767.48
| Professional | | $1,242.35 | $2,002.58 | $2,767.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,396.44 / $3,590.97 / $27,598.19
| Facility | | $2,396.44 | $3,590.97 | $27,598.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.06 / $3,100.96 / $3,413.47
| Facility | | $1,978.06 | $3,100.96 | $3,413.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |