- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,467.37 / $5,888.44
| Facility | | $2,238.72 | $3,467.37 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $5,888.44
| Professional | | $2,238.72 | $2,238.72 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $9,332.54 / $10,964.78
| Facility | | $5,370.32 | $9,332.54 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $16,982.44 / $17,782.79
| Facility | | $15,848.93 | $16,982.44 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $407.38 / $1,202.26
| Professional | | $281.84 | $407.38 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,548.13 / $10,715.19
| Facility | | $2,290.87 | $3,548.13 | $10,715.19 |