- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,265.80 / $12,589.25
| Facility | | $1,548.82 | $4,265.80 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,995.26 / $3,890.45
| Facility | | $1,548.82 | $1,995.26 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $758.58 / $2,137.96
| Facility | | $134.90 | $758.58 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $1,445.44 / $2,570.40
| Professional | | $316.23 | $1,445.44 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,162.28 / $8,128.31
| Facility | | $2,398.83 | $3,162.28 | $8,128.31 |