- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,398.83
| Facility | | $1,258.93 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Professional | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $14,125.38 / $19,054.61
| Facility | | $11,748.98 | $14,125.38 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $12,022.64 / $22,908.68
| Facility | | $5,248.07 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,413.10 / $26,302.68
| Facility | | $2,511.89 | $7,413.10 | $26,302.68 |