- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,659.59 / $2,511.89
| Facility | | $870.96 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $2,187.76 / $7,943.28
| Professional | | $812.83 | $2,187.76 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $16,218.10
| Facility | | $11,748.98 | $11,748.98 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $18,197.01
| Facility | | $3,715.35 | $7,762.47 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $2,818.38
| Professional | | $1,023.29 | $1,380.38 | $2,818.38 |