- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,981.07 / $13,803.84
| Facility | | $3,162.28 | $3,981.07 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,311.31 / $4,073.80
| Professional | | $1,513.56 | $3,311.31 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $7,943.28
| Facility | | $2,137.96 | $3,019.95 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $3,235.94
| Facility | | $2,454.71 | $3,090.30 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $3,981.07
| Facility | | $1,905.46 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Facility | | $8,511.38 | $8,511.38 | $8,511.38 |
- 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 |