- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,630.27 / $6,606.93
| Facility | | $1,096.48 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $9,772.37 / $9,772.37
| Professional | | $2,570.40 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $7,943.28 / $13,489.63
| Facility | | $2,754.23 | $7,943.28 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,915.35 / $26,915.35 / $26,915.35
| Facility | | $26,915.35 | $26,915.35 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,630.78 / $6,309.57
| Facility | | $2,041.74 | $3,630.78 | $6,309.57 |