- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,981.07 / $7,762.47
| Facility | | $1,659.59 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $4,168.69
| Professional | | $2,398.83 | $3,467.37 | $4,168.69 |
- 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
- $1,698.24 / $1,778.28 / $3,467.37
| Professional | | $1,698.24 | $1,778.28 | $3,467.37 |
- 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 |