- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,884.03 / $5,888.44
| Facility | | $1,621.81 | $2,884.03 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,025.60 / $7,762.47
| Facility | | $4,466.84 | $6,025.60 | $7,762.47 |
- 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
- $19.05 / $1,445.44 / $2,137.96
| Professional | | $19.05 | $1,445.44 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,905.46 / $6,606.93
| Facility | | $776.25 | $1,905.46 | $6,606.93 |