- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,388.44 / $6,760.83
| Facility | | $2,818.38 | $3,388.44 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Professional | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $16,218.10 / $31,622.78
| Facility | | $8,709.64 | $16,218.10 | $31,622.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $28,183.83
| Facility | | $8,511.38 | $13,489.63 | $28,183.83 |