- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,585.78 / $14,454.40
| Facility | | $4,265.80 | $7,585.78 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $10,964.78
| Facility | | $4,265.80 | $5,623.41 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,230.27 / $6,760.83
| Facility | | $575.44 | $1,230.27 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $1,995.26
| Professional | | $1,202.26 | $1,412.54 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $8,128.31
| Facility | | $2,630.27 | $3,630.78 | $8,128.31 |