- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,754.40 / $12,302.69
| Facility | | $2,818.38 | $5,754.40 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $21,877.62 / $22,908.68
| Professional | | $2,818.38 | $21,877.62 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $13,489.63 / $14,125.38
| Facility | | $3,890.45 | $13,489.63 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,165.95 / $12,882.50
| Facility | | $1,737.80 | $6,165.95 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,918.31 / $12,302.69
| Facility | | $2,818.38 | $6,918.31 | $12,302.69 |