- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,630.78 / $23,988.33
| Facility | | $2,951.21 | $3,630.78 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,019.95 / $3,715.35
| Professional | | $1,348.96 | $3,019.95 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $23,988.33
| Facility | | $1,949.84 | $2,818.38 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,818.38 / $3,019.95
| Facility | | $2,454.71 | $2,818.38 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,548.13
| Facility | | $1,548.82 | $2,041.74 | $3,548.13 |
- 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 |