- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,089.30 / $5,011.87
| Facility | | $758.58 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $181.97 / $213.80
| Professional | | $154.88 | $181.97 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $7,762.47
| Facility | | $3,715.35 | $6,025.60 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $457.09 / $630.96
| Professional | | $213.80 | $457.09 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,570.40 / $6,606.93
| Facility | | $1,071.52 | $2,570.40 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $223.87 / $354.81
| Professional | | $177.83 | $223.87 | $354.81 |