- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $11,481.54 / $18,620.87
| Facility | | $5,248.07 | $11,481.54 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $12,022.64
| Facility | | $3,630.78 | $4,897.79 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,981.07 / $6,165.95
| Professional | | $2,630.27 | $3,981.07 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $2,187.76 / $6,606.93
| Facility | | $851.14 | $2,187.76 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $2,570.40
| Professional | | $1,202.26 | $1,584.89 | $2,570.40 |