- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,365.16 / $7,762.47
| Facility | | $2,238.72 | $4,365.16 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $15,848.93 / $15,848.93
| Professional | | $4,466.84 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $14,454.40 / $20,892.96
| Facility | | $8,912.51 | $14,454.40 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $13,182.57 / $13,182.57
| Facility | | $13,182.57 | $13,182.57 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $14,454.40
| Facility | | $14,454.40 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,309.57 / $14,791.08
| Facility | | $3,715.35 | $6,309.57 | $14,791.08 |