- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,884.03 / $6,165.95
| Facility | | $2,137.96 | $2,884.03 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $5,888.44
| Facility | | $3,388.44 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,995.26 / $2,041.74
| Facility | | $1,479.11 | $1,995.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $251.19 / $1,479.11
| Professional | | $87.10 | $251.19 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Facility | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,187.76 / $7,244.36
| Facility | | $891.25 | $2,187.76 | $7,244.36 |