- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $11,481.54 / $24,547.09
| Facility | | $1,023.29 | $11,481.54 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $2,137.96 / $3,311.31
| Professional | | $151.36 | $2,137.96 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |