- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $6,025.60 / $8,709.64
| Facility | | $1,621.81 | $6,025.60 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $4,365.16
| Professional | | $1,621.81 | $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
- $7,244.36 / $8,511.38 / $19,952.62
| Facility | | $7,244.36 | $8,511.38 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,128.61 / $7,079.46
| Facility | | $1,995.26 | $5,128.61 | $7,079.46 |