- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $10,000.00 / $14,125.38
| Facility | | $4,570.88 | $10,000.00 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $11,748.98 / $16,595.87
| Professional | | $5,754.40 | $11,748.98 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,442.29 / $38,018.94 / $57,543.99
| Facility | | $23,442.29 | $38,018.94 | $57,543.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $10,715.19 / $29,512.09
| Facility | | $5,128.61 | $10,715.19 | $29,512.09 |