- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,466.84 / $8,511.38
| Facility | | $1,819.70 | $4,466.84 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $3,715.35
| Professional | | $1,621.81 | $1,819.70 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |
- 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
- $1,659.59 / $2,691.53 / $5,888.44
| Facility | | $1,659.59 | $2,691.53 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $5,248.07
| Facility | | $1,819.70 | $2,818.38 | $5,248.07 |