- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,691.53 / $6,165.95
| Facility | | $891.25 | $2,691.53 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $2,089.30 / $6,165.95
| Professional | | $512.86 | $2,089.30 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,079.46 / $10,232.93
| Facility | | $3,467.37 | $7,079.46 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $10,232.93 / $10,232.93
| Facility | | $2,818.38 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $10,232.93
| Facility | | $3,235.94 | $5,754.40 | $10,232.93 |