- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,365.16 / $6,918.31
| Facility | | $2,238.72 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $22,908.68 / $22,908.68
| Professional | | $4,466.84 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $9,332.54 / $13,489.63
| Facility | | $6,165.95 | $9,332.54 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Facility | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,786.30 / $12,022.64
| Facility | | $2,951.21 | $4,786.30 | $12,022.64 |