- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,090.30 / $7,943.28
| Facility | | $1,659.59 | $3,090.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,570.40 / $3,235.94
| Professional | | $1,949.84 | $2,570.40 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $3,467.37
| Facility | | $1,258.93 | $1,862.09 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $2,630.27
| Facility | | $1,862.09 | $2,454.71 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $3,019.95
| Facility | | $1,230.27 | $1,737.80 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- 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 |