- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $8,709.64 / $13,803.84
| Facility | | $1,348.96 | $8,709.64 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,584.89 / $2,570.40
| Facility | | $1,174.90 | $1,584.89 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $15,135.61 / $22,908.68
| Facility | | $5,370.32 | $15,135.61 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Facility | | $8,511.38 | $8,511.38 | $8,511.38 |