- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $9,549.93 / $18,197.01
| Facility | | $5,370.32 | $9,549.93 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $12,589.25 / $24,547.09
| Facility | | $9,549.93 | $12,589.25 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,041.74 / $4,265.80
| Facility | | $1,258.93 | $2,041.74 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $4,570.88
| Professional | | $2,754.23 | $3,388.44 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,570.88 / $13,803.84
| Facility | | $3,235.94 | $4,570.88 | $13,803.84 |