- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,691.53 / $4,365.16
| Facility | | $724.44 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $676.08 / $776.25
| Professional | | $239.88 | $676.08 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,762.47 / $11,748.98
| Facility | | $3,981.07 | $7,762.47 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,128.61 / $11,220.18
| Facility | | $1,148.15 | $5,128.61 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $758.58 / $1,348.96
| Professional | | $588.84 | $758.58 | $1,348.96 |