- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,317.64 / $13,489.63
| Facility | | $4,466.84 | $8,317.64 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,995.26
| Professional | | $1,096.48 | $1,096.48 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $17,782.79 / $29,512.09
| Facility | | $11,481.54 | $17,782.79 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $8,709.64 / $21,379.62
| Facility | | $3,890.45 | $8,709.64 | $21,379.62 |