- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $3,801.89 / $11,481.54
| Facility | | $549.54 | $3,801.89 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,511.38 / $16,595.87
| Facility | | $6,456.54 | $8,511.38 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $630.96 / $1,174.90
| Facility | | $371.54 | $630.96 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,174.90 / $1,479.11
| Professional | | $891.25 | $1,174.90 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,162.28 / $8,128.31
| Facility | | $1,905.46 | $3,162.28 | $8,128.31 |