- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,682.04 / $1,954.80 / $2,027.54
| Facility | | $1,682.04 | $1,954.80 | $2,027.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,228.00 / $2,246.48 / $3,184.06
| Facility | | $1,228.00 | $2,246.48 | $3,184.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.02 / $498.89 / $1,168.58
| Professional | | $439.02 | $498.89 | $1,168.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.97 / $480.97 / $595.90
| Professional | | $480.97 | $480.97 | $595.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,172.45 / $9,172.45 / $9,172.45
| Facility | | $9,172.45 | $9,172.45 | $9,172.45 |