- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $6,606.93 / $12,589.25
| Facility | | $2,344.23 | $6,606.93 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,445.44
| Professional | | $812.83 | $812.83 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,456.54 / $12,589.25
| Facility | | $5,011.87 | $6,456.54 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,230.27 / $4,365.16
| Facility | | $302.00 | $1,230.27 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $1,230.27 / $4,466.84
| Facility | | $309.03 | $1,230.27 | $4,466.84 |