- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,162.28 / $6,760.83
| Facility | | $1,548.82 | $3,162.28 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,548.82 / $2,818.38
| Professional | | $870.96 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,995.26 / $7,413.10
| Facility | | $954.99 | $1,995.26 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $2,511.89
| Professional | | $1,548.82 | $2,137.96 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,918.31 / $9,772.37
| Facility | | $3,630.78 | $6,918.31 | $9,772.37 |