- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,183.06 / $7,948.98 / $13,979.78
| Facility | | $3,183.06 | $7,948.98 | $13,979.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,069.78 / $5,247.82 / $10,481.23
| Facility | | $4,069.78 | $5,247.82 | $10,481.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,500.40 / $4,646.42 / $6,080.65
| Professional | | $3,500.40 | $4,646.42 | $6,080.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,240.00 / $3,240.00 / $3,240.00
| Facility | | $3,240.00 | $3,240.00 | $3,240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.08 / $2,040.55 / $2,584.44
| Professional | | $1,407.08 | $2,040.55 | $2,584.44 |