- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $8,709.64 / $12,589.25
| Facility | | $1,659.59 | $8,709.64 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $11,220.18 / $11,220.18
| Professional | | $1,905.46 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $13,182.57 / $26,915.35
| Facility | | $12,302.69 | $13,182.57 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,244.36 / $10,471.29
| Facility | | $2,511.89 | $7,244.36 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $15,848.93 / $15,848.93
| Facility | | $15,848.93 | $15,848.93 | $15,848.93 |