- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,238.72 / $7,943.28
| Facility | | $1,348.96 | $2,238.72 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $2,344.23
| Professional | | $1,412.54 | $1,862.09 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $2,884.03
| Facility | | $1,071.52 | $1,348.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $1,862.09
| Facility | | $1,513.56 | $1,778.28 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $2,290.87
| Facility | | $1,047.13 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- 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 |