- 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
- $1,071.52 / $3,630.78 / $9,549.93
| Professional | | $1,071.52 | $3,630.78 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $794.33 / $2,570.40
| Facility | | $54.95 | $794.33 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $794.33 / $2,570.40
| Facility | | $467.74 | $794.33 | $2,570.40 |