- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,819.70 / $2,454.71
| Facility | | $1,071.52 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,778.28 / $2,238.72
| Professional | | $1,071.52 | $1,778.28 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $14,791.08
| Facility | | $10,964.78 | $10,964.78 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $16,595.87
| Facility | | $2,187.76 | $5,888.44 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,041.74 / $3,801.89
| Professional | | $1,621.81 | $2,041.74 | $3,801.89 |