- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $7,244.36 / $13,489.63
| Facility | | $1,288.25 | $7,244.36 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,162.28 / $6,165.95
| Facility | | $2,398.83 | $3,162.28 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $812.83 / $6,309.57
| Facility | | $501.19 | $812.83 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,513.56
| Professional | | $933.25 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,495.41 / $8,128.31
| Facility | | $3,630.78 | $5,495.41 | $8,128.31 |