- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,311.31 / $8,511.38
| Facility | | $1,071.52 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $3,981.07
| Professional | | $3,801.89 | $3,890.45 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $15,848.93 / $23,442.29
| Facility | | $8,511.38 | $15,848.93 | $23,442.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $6,918.31 / $14,791.08
| Facility | | $1,202.26 | $6,918.31 | $14,791.08 |