- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $14,125.38 / $28,183.83
| Facility | | $4,265.80 | $14,125.38 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $9,120.11 / $21,379.62
| Facility | | $6,456.54 | $9,120.11 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,456.54 / $10,232.93
| Professional | | $5,011.87 | $6,456.54 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $2,238.72 / $6,456.54
| Facility | | $912.01 | $2,238.72 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $4,466.84
| Professional | | $2,089.30 | $2,754.23 | $4,466.84 |