- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,309.57 / $9,549.93
| Facility | | $4,265.80 | $6,309.57 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $11,220.18 / $11,220.18
| Professional | | $5,128.61 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,801.89 / $7,244.36
| Facility | | $1,479.11 | $3,801.89 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,168.69 / $6,918.31
| Facility | | $1,202.26 | $4,168.69 | $6,918.31 |