- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $7,413.10 / $12,022.64
| Facility | | $1,698.24 | $7,413.10 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,584.89 / $2,344.23
| Facility | | $489.78 | $1,584.89 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $114.82 / $204.17
| Professional | | $89.13 | $114.82 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $2,454.71
| Facility | | $954.99 | $954.99 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,318.26 / $2,454.71
| Facility | | $1,202.26 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $2,137.96
| Facility | | $954.99 | $954.99 | $2,137.96 |