- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $2,454.71 / $5,011.87
| Facility | | $245.47 | $2,454.71 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $5,888.44
| Facility | | $3,388.44 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $295.12 / $1,288.25
| Professional | | $123.03 | $295.12 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,290.87 / $6,456.54
| Facility | | $724.44 | $2,290.87 | $6,456.54 |