- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $8,511.38 / $10,471.29
| Facility | | $1,698.24 | $8,511.38 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $1,819.70
| Professional | | $1,621.81 | $1,819.70 | $1,819.70 |
- 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
- $1,621.81 / $1,819.70 / $3,090.30
| Facility | | $1,621.81 | $1,819.70 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,244.36 / $10,471.29
| Facility | | $2,511.89 | $7,244.36 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,387.21 / $22,387.21 / $22,387.21
| Facility | | $22,387.21 | $22,387.21 | $22,387.21 |