- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,981.07 / $7,762.47
| Facility | | $1,584.89 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $7,762.47
| Facility | | $3,715.35 | $6,025.60 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $2,454.71
| Professional | | $1,318.26 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,090.30 / $9,120.11
| Facility | | $1,659.59 | $3,090.30 | $9,120.11 |