- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,823.96 / $5,772.54 / $19,568.89
| Facility | | $4,823.96 | $5,772.54 | $19,568.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $3,859.17 / $3,859.17
| Professional | | $3,859.17 | $3,859.17 | $3,859.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,729.26 / $3,859.17 / $3,875.94
| Facility | | $1,729.26 | $3,859.17 | $3,875.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,729.26 / $3,859.17 / $3,875.94
| Facility | | $1,729.26 | $3,859.17 | $3,875.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |