- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,762.47 / $16,595.87
| Facility | | $3,801.89 | $7,762.47 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $9,120.11
| Professional | | $3,801.89 | $3,801.89 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,148.15 / $2,041.74
| Facility | | $602.56 | $1,148.15 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $6,760.83 / $10,471.29
| Facility | | $1,479.11 | $6,760.83 | $10,471.29 |