- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $6,309.57
| Facility | | $4,073.80 | $4,073.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,905.46 / $2,818.38
| Professional | | $1,819.70 | $1,905.46 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $16,218.10 / $41,686.94
| Facility | | $9,120.11 | $16,218.10 | $41,686.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $9,772.37 / $15,135.61
| Facility | | $3,981.07 | $9,772.37 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,709.64 / $15,135.61
| Facility | | $3,311.31 | $8,709.64 | $15,135.61 |