- 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
- $7,585.78 / $10,000.00 / $19,498.45
| Facility | | $7,585.78 | $10,000.00 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $691.83 / $5,623.41
| Facility | | $398.11 | $691.83 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $1,318.26
| Professional | | $831.76 | $1,023.29 | $1,318.26 |
- 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 |