- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $9,772.37
| Facility | | $1,819.70 | $2,818.38 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $288.40 / $346.74
| Professional | | $144.54 | $288.40 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,022.64 / $22,908.68
| Facility | | $10,964.78 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | | $9,549.93 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | | $9,549.93 | $9,549.93 | $9,549.93 |