- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,818.38 / $6,456.54
| Facility | | $1,148.15 | $2,818.38 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $11,220.18 / $11,220.18
| Professional | | $2,818.38 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,370.32 / $9,332.54
| Facility | | $2,511.89 | $5,370.32 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $15,848.93 / $15,848.93
| Facility | | $15,848.93 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,630.78 / $6,309.57
| Facility | | $2,041.74 | $3,630.78 | $6,309.57 |