- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,884.03 / $7,943.28
| Facility | | $1,584.89 | $2,884.03 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,454.71 / $2,951.21
| Professional | | $1,096.48 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,238.72 / $3,388.44
| Facility | | $1,584.89 | $2,238.72 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $2,454.71
| Facility | | $1,778.28 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $3,019.95
| Facility | | $1,348.96 | $1,949.84 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- 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 |