- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $4,073.80 / $8,128.31
| Facility | | $1,621.81 | $4,073.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $8,128.31 / $8,128.31
| Professional | | $1,348.96 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $3,630.78
| Facility | | $912.01 | $912.01 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,884.03 / $6,456.54
| Facility | | $977.24 | $2,884.03 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,884.03 / $4,677.35
| Facility | | $1,047.13 | $2,884.03 | $4,677.35 |