- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,011.87 / $12,589.25
| Facility | | $1,148.15 | $5,011.87 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $12,882.50
| Facility | | $5,128.61 | $6,606.93 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $831.76 / $5,370.32
| Facility | | $436.52 | $831.76 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $1,548.82
| Professional | | $891.25 | $1,230.27 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,011.87 / $8,128.31
| Facility | | $3,630.78 | $5,011.87 | $8,128.31 |