- 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 / $18,197.01 / $18,197.01
| Professional | | $4,466.84 | $18,197.01 | $18,197.01 |
- 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
- $13,803.84 / $13,803.84 / $13,803.84
| Facility | | $13,803.84 | $13,803.84 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,791.08 / $14,791.08 / $14,791.08
| Facility | | $14,791.08 | $14,791.08 | $14,791.08 |
- 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 |