- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $5,011.87
| Facility | | $1,584.89 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,630.78 / $10,232.93
| Professional | | $1,862.09 | $3,630.78 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $9,120.11 / $16,595.87
| Facility | | $3,467.37 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $398.11 / $1,318.26
| Professional | | $275.42 | $398.11 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,047.13 / $1,995.26
| Facility | | $199.53 | $1,047.13 | $1,995.26 |