- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,495.41 / $11,220.18
| Facility | | $1,202.26 | $5,495.41 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $11,220.18 / $11,220.18
| Professional | | $870.96 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $2,818.38 / $3,311.31
| Facility | | $323.59 | $2,818.38 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,659.59 / $1,778.28
| Facility | | $1,548.82 | $1,659.59 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,754.40 / $9,772.37
| Facility | | $1,737.80 | $5,754.40 | $9,772.37 |