- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,819.70 / $2,290.87
| Facility | | $1,412.54 | $1,819.70 | $2,290.87 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- 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
- $2,454.71 / $2,454.71 / $15,135.61
| Facility | | $2,454.71 | $2,454.71 | $15,135.61 |