- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,025.60 / $11,481.54
| Facility | | $2,398.83 | $6,025.60 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,288.25 / $1,862.09
| Professional | | $645.65 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,022.64 / $22,908.68
| Facility | | $10,964.78 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |