- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,943.28 / $14,454.40
| Facility | | $6,025.60 | $7,943.28 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $12,882.50
| Facility | | $5,128.61 | $6,606.93 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,659.59 / $7,943.28
| Facility | | $794.33 | $1,659.59 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,862.09 / $2,511.89
| Professional | | $1,778.28 | $1,862.09 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,011.87 / $8,128.31
| Facility | | $3,630.78 | $5,011.87 | $8,128.31 |