- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $9,772.37
| Facility | | $1,819.70 | $2,398.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,041.74
| Professional | | $1,995.26 | $1,995.26 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $2,630.27
| Facility | | $1,288.25 | $1,412.54 | $2,630.27 |
- 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 |