- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $4,365.16
| Facility | | $2,290.87 | $2,290.87 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Professional | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $11,481.54 / $16,218.10
| Facility | | $2,691.53 | $11,481.54 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |