- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $8,511.38 / $16,982.44
| Facility | | $3,630.78 | $8,511.38 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Professional | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,549.93 / $10,964.78
| Facility | | $6,760.83 | $9,549.93 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,737.80 / $7,943.28
| Facility | | $776.25 | $1,737.80 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $5,623.41
| Facility | | $851.14 | $1,445.44 | $5,623.41 |