- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,025.60 / $9,332.54
| Facility | | $3,162.28 | $6,025.60 | $9,332.54 |
- 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
- $13,803.84 / $16,218.10 / $36,307.81
| Facility | | $13,803.84 | $16,218.10 | $36,307.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,128.61 / $15,848.93
| Facility | | $3,019.95 | $5,128.61 | $15,848.93 |