- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $11,481.54 / $16,595.87
| Facility | | $10,715.19 | $11,481.54 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,488.17 / $28,183.83 / $69,183.10
| Facility | | $15,488.17 | $28,183.83 | $69,183.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,467.37 / $8,709.64
| Facility | | $1,737.80 | $3,467.37 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $3,235.94
| Professional | | $1,621.81 | $2,290.87 | $3,235.94 |