- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,370.32 / $10,715.19
| Facility | | $1,737.80 | $5,370.32 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $8,912.51 / $12,589.25
| Professional | | $3,235.94 | $8,912.51 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,549.93 / $17,378.01
| Facility | | $4,570.88 | $9,549.93 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $295.12 / $416.87
| Professional | | $234.42 | $295.12 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,128.61
| Professional | | $5,011.87 | $5,011.87 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $13,803.84 / $23,988.33
| Facility | | $10,471.29 | $13,803.84 | $23,988.33 |