- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,951.21 / $6,456.54
| Facility | | $1,258.93 | $2,951.21 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,621.81 / $2,691.53
| Professional | | $954.99 | $1,621.81 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,079.46 / $10,232.93
| Facility | | $3,467.37 | $7,079.46 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $10,232.93 / $10,232.93
| Facility | | $2,818.38 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $10,232.93
| Facility | | $3,235.94 | $5,754.40 | $10,232.93 |