- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,834.13 / $5,909.48 / $13,841.56
| Facility | | $2,834.13 | $5,909.48 | $13,841.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.47 / $1,545.47 / $1,545.47
| Professional | | $1,545.47 | $1,545.47 | $1,545.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,904.89 / $9,357.90 / $17,567.16
| Facility | | $6,904.89 | $9,357.90 | $17,567.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,262.77 / $8,636.81 / $9,719.69
| Facility | | $7,262.77 | $8,636.81 | $9,719.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,939.00 / $8,158.00 / $9,496.00
| Facility | | $6,939.00 | $8,158.00 | $9,496.00 |