- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,754.40 / $7,943.28
| Facility | | $3,162.28 | $5,754.40 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,897.79 / $6,025.60
| Professional | | $2,238.72 | $4,897.79 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,466.84 / $6,760.83
| Facility | | $3,162.28 | $4,466.84 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,466.84 / $4,786.30
| Facility | | $3,715.35 | $4,466.84 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $5,754.40
| Facility | | $2,818.38 | $3,548.13 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $12,589.25 / $12,589.25
| Facility | | $12,589.25 | $12,589.25 | $12,589.25 |
- 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 |