- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,022.64 / $16,595.87
| Facility | | $9,772.37 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $2,691.53
| Facility | | $1,862.09 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,862.09 / $1,862.09
| Professional | | $60.26 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $2,691.53
| Facility | | $1,862.09 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |