- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,041.74 / $4,570.88
| Facility | | $891.25 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $3,311.31 / $6,456.54
| Professional | | $616.60 | $3,311.31 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $20,417.38 / $30,902.95
| Facility | | $10,715.19 | $20,417.38 | $30,902.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $9,772.37 / $24,547.09
| Facility | | $1,202.26 | $9,772.37 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $891.25 / $1,949.84
| Professional | | $457.09 | $891.25 | $1,949.84 |