- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,338.00 / $4,338.00 / $11,226.02
| Facility | | $4,338.00 | $4,338.00 | $11,226.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,895.24 / $10,895.24 / $10,895.24
| Professional | | $10,895.24 | $10,895.24 | $10,895.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $18,412.96 / $29,852.96
| Facility | | $6,571.00 | $18,412.96 | $29,852.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,361.15 / $11,361.15 / $13,254.68
| Facility | | $11,361.15 | $11,361.15 | $13,254.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $6,571.00 / $6,571.00
| Facility | | $6,571.00 | $6,571.00 | $6,571.00 |