- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,466.84 / $7,943.28
| Facility | | $2,344.23 | $4,466.84 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $4,570.88
| Professional | | $2,754.23 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,754.23 / $5,011.87
| Facility | | $1,778.28 | $2,754.23 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $3,715.35
| Facility | | $2,691.53 | $3,467.37 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,511.89 / $4,365.16
| Facility | | $1,778.28 | $2,511.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | | $9,549.93 | $9,549.93 | $9,549.93 |
- 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 |