- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,309.57 / $10,471.29
| Facility | | $3,162.28 | $6,309.57 | $10,471.29 |
- 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
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $436.52 / $1,698.24
| Facility | | $54.95 | $436.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $416.87 / $1,778.28
| Facility | | $173.78 | $416.87 | $1,778.28 |