- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,137.96 / $7,943.28
| Facility | | $1,258.93 | $2,137.96 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,737.80 / $2,187.76
| Professional | | $1,348.96 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $2,238.72
| Facility | | $977.24 | $1,288.25 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $1,737.80
| Facility | | $1,318.26 | $1,659.59 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,258.93 / $2,089.30
| Facility | | $977.24 | $1,258.93 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $10,232.93 / $37,153.52
| Facility | | $2,454.71 | $10,232.93 | $37,153.52 |