- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,981.07 / $9,772.37
| Facility | | $1,445.44 | $3,981.07 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,309.57 / $9,772.37
| Professional | | $3,890.45 | $6,309.57 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $5,011.87
| Facility | | $1,905.46 | $1,905.46 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $9,549.93 / $21,379.62
| Facility | | $3,235.94 | $9,549.93 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $11,748.98 / $20,892.96
| Facility | | $3,467.37 | $11,748.98 | $20,892.96 |