- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,235.94 / $6,760.83
| Facility | | $1,318.26 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,380.38 / $3,630.78
| Professional | | $741.31 | $1,380.38 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,698.24 / $13,489.63
| Facility | | $776.25 | $1,698.24 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,089.30
| Professional | | $1,288.25 | $1,698.24 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,606.93 / $15,848.93
| Facility | | $2,951.21 | $6,606.93 | $15,848.93 |