- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,884.03
| Facility | | $2,137.96 | $2,137.96 | $2,884.03 |
- 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
- $707.95 / $1,412.54 / $1,412.54
| Facility | | $707.95 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $371.54 / $426.58
| Professional | | $295.12 | $371.54 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43,651.58 / $52,480.75 / $66,069.34
| Facility | | $43,651.58 | $52,480.75 | $66,069.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |