- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,659.59 / $2,454.71
| Facility | | $870.96 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $251.19 / $977.24
| Professional | | $131.83 | $251.19 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $5,248.07
| Facility | | $3,801.89 | $3,801.89 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $10,471.29
| Facility | | $1,230.27 | $2,951.21 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $288.40 / $467.74
| Professional | | $204.17 | $288.40 | $467.74 |