- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,884.03 / $5,128.61
| Facility | | $1,862.09 | $2,884.03 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Professional | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,165.95 / $14,125.38
| Facility | | $2,570.40 | $6,165.95 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,918.31 / $15,488.17
| Facility | | $2,570.40 | $6,918.31 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,165.95 / $14,125.38
| Facility | | $2,570.40 | $6,165.95 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,888.44 / $14,125.38
| Facility | | $2,089.30 | $5,888.44 | $14,125.38 |