- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,073.80 / $12,589.25
| Facility | | $2,041.74 | $4,073.80 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,370.32 / $10,471.29
| Facility | | $4,073.80 | $5,370.32 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $288.40 / $1,949.84
| Facility | | $177.83 | $288.40 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $436.52 / $602.56
| Professional | | $371.54 | $436.52 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,162.28 / $8,128.31
| Facility | | $1,479.11 | $3,162.28 | $8,128.31 |