- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,819.70 / $4,073.80
| Facility | | $467.74 | $1,819.70 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $2,570.40 / $4,073.80
| Professional | | $851.14 | $2,570.40 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,019.95 / $3,981.07
| Facility | | $1,659.59 | $3,019.95 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $10,964.78
| Professional | | $10,964.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $4,073.80
| Facility | | $1,202.26 | $2,290.87 | $4,073.80 |