- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,244.36 / $11,748.98
| Facility | | $4,365.16 | $7,244.36 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $4,570.88
| Professional | | $1,621.81 | $1,819.70 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $16,218.10 / $25,703.96
| Facility | | $10,964.78 | $16,218.10 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,606.93 / $10,964.78
| Facility | | $2,884.03 | $6,606.93 | $10,964.78 |