- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,623.41 / $12,302.69
| Facility | | $1,819.70 | $5,623.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $4,365.16
| Professional | | $1,258.93 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $5,623.41
| Facility | | $1,479.11 | $2,187.76 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,630.78 / $5,623.41
| Facility | | $1,548.82 | $3,630.78 | $5,623.41 |