- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,090.30 / $7,943.28
| Facility | | $1,698.24 | $3,090.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,630.27 / $3,235.94
| Professional | | $1,174.90 | $2,630.27 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $3,630.78
| Facility | | $1,698.24 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,454.71 / $2,630.27
| Facility | | $2,089.30 | $2,454.71 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,235.94
| Facility | | $1,479.11 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- 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 |