- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,623.41 / $12,589.25
| Facility | | $2,511.89 | $5,623.41 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $12,589.25 / $16,595.87
| Professional | | $4,570.88 | $12,589.25 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,162.28 / $14,125.38
| Facility | | $3,090.30 | $3,162.28 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $7,079.46 / $46,773.51
| Facility | | $1,584.89 | $7,079.46 | $46,773.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,025.60 / $23,442.29
| Facility | | $4,168.69 | $6,025.60 | $23,442.29 |