- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,495.41 / $7,943.28
| Facility | | $2,951.21 | $5,495.41 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,570.88 / $5,623.41
| Professional | | $2,089.30 | $4,570.88 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,235.94 / $7,943.28
| Facility | | $2,951.21 | $3,235.94 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,265.80 / $4,466.84
| Facility | | $3,715.35 | $4,265.80 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $5,370.32
| Facility | | $2,454.71 | $3,090.30 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- 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 |