- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,606.93 / $21,877.62
| Facility | | $6,456.54 | $6,606.93 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $2,238.72 / $8,511.38
| Professional | | $245.47 | $2,238.72 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $8,912.51 / $16,218.10
| Facility | | $8,912.51 | $8,912.51 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,995.26 / $2,511.89
| Facility | | $1,659.59 | $1,995.26 | $2,511.89 |