- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,724.00 / $10,915.56 / $21,899.37
| Facility | | $5,724.00 | $10,915.56 | $21,899.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.00 / $1,736.36 / $12,082.08
| Professional | | $1,161.00 | $1,736.36 | $12,082.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,474.97 / $6,064.74 / $11,385.07
| Facility | | $4,474.97 | $6,064.74 | $11,385.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $7,307.60 / $8,223.82
| Facility | | $4,217.00 | $7,307.60 | $8,223.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,231.26 / $5,077.51 / $6,628.97
| Facility | | $4,231.26 | $5,077.51 | $6,628.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $6,451.00 / $7,934.00
| Facility | | $4,217.00 | $6,451.00 | $7,934.00 |