- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,951.21 / $23,988.33
| Facility | | $2,398.83 | $2,951.21 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,454.71 / $3,019.95
| Professional | | $1,096.48 | $2,454.71 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $23,988.33
| Facility | | $1,584.89 | $2,290.87 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,290.87 / $2,398.83
| Facility | | $1,995.26 | $2,290.87 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,659.59 / $2,884.03
| Facility | | $1,258.93 | $1,659.59 | $2,884.03 |
- 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 |