- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,818.38 / $5,888.44
| Facility | | $1,148.15 | $2,818.38 | $5,888.44 |
- 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
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.37 / $467.74 / $933.25
| Professional | | $4.37 | $467.74 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,951.21 / $7,413.10
| Facility | | $1,288.25 | $2,951.21 | $7,413.10 |