- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,754.40 / $13,489.63
| Facility | | $3,019.95 | $5,754.40 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $3,019.95
| Facility | | $912.01 | $1,258.93 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $416.87 / $478.63
| Professional | | $380.19 | $416.87 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,137.96 / $6,456.54
| Facility | | $724.44 | $2,137.96 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $363.08 / $588.84
| Professional | | $281.84 | $363.08 | $588.84 |