- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,623.41 / $10,471.29
| Facility | | $3,019.95 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $6,760.83
| Professional | | $3,801.89 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,248.07 / $11,748.98
| Facility | | $2,691.53 | $5,248.07 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,918.31 / $11,748.98
| Facility | | $2,818.38 | $6,918.31 | $11,748.98 |