- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,890.45 / $7,762.47
| Facility | | $1,445.44 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $4,365.16
| Professional | | $1,621.81 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,220.18 / $18,620.87
| Facility | | $7,244.36 | $11,220.18 | $18,620.87 |
- 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
- $891.25 / $2,137.96 / $5,754.40
| Facility | | $891.25 | $2,137.96 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,311.31 / $6,165.95
| Facility | | $891.25 | $3,311.31 | $6,165.95 |