- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $4,466.84 / $10,232.93
| Facility | | $2,137.96 | $4,466.84 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $4,466.84 / $10,232.93
| Professional | | $645.65 | $4,466.84 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $9,120.11 / $16,595.87
| Facility | | $3,467.37 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $870.96 / $3,467.37
| Professional | | $645.65 | $870.96 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $1,584.89 / $4,786.30
| Facility | | $407.38 | $1,584.89 | $4,786.30 |