- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,165.95 / $12,589.25
| Facility | | $2,187.76 | $6,165.95 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $194.98 / $1,445.44
| Professional | | $194.98 | $194.98 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,162.28 / $6,165.95
| Facility | | $2,398.83 | $3,162.28 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,309.57 / $7,943.28
| Facility | | $4,265.80 | $6,309.57 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,495.41 / $8,128.31
| Facility | | $3,630.78 | $5,495.41 | $8,128.31 |