- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,011.87 / $12,882.50
| Facility | | $1,122.02 | $5,011.87 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,760.83 / $7,413.10
| Facility | | $5,888.44 | $6,760.83 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,122.02 / $1,318.26
| Professional | | $891.25 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $1,698.24
| Professional | | $1,318.26 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $1,905.46
| Facility | | $812.83 | $1,148.15 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,380.38 / $10,964.78
| Facility | | $891.25 | $1,380.38 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,882.50 / $29,512.09
| Facility | | $7,413.10 | $12,882.50 | $29,512.09 |