- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,888.44 / $7,943.28
| Facility | | $3,235.94 | $5,888.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,011.87 / $6,165.95
| Professional | | $2,290.87 | $5,011.87 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,570.88 / $6,918.31
| Facility | | $3,235.94 | $4,570.88 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,570.88 / $4,897.79
| Facility | | $3,801.89 | $4,570.88 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,715.35 / $6,025.60
| Facility | | $2,884.03 | $3,715.35 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Facility | | $12,882.50 | $12,882.50 | $12,882.50 |
- 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 |