- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,981.07 / $6,760.83
| Facility | | $3,388.44 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,344.23 / $2,344.23
| Professional | | $1,412.54 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,748.98 / $15,848.93
| Facility | | $7,413.10 | $11,748.98 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,715.19 / $15,848.93
| Facility | | $7,413.10 | $10,715.19 | $15,848.93 |