- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $8,511.38 / $14,454.40
| Facility | | $7,244.36 | $8,511.38 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Professional | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,495.41 / $10,715.19
| Facility | | $4,168.69 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,715.35 / $7,943.28
| Facility | | $2,818.38 | $3,715.35 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $8,128.31
| Facility | | $2,630.27 | $3,162.28 | $8,128.31 |