- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $234.42 / $616.60
| Professional | | $173.78 | $234.42 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,918.31 / $14,454.40
| Facility | | $3,630.78 | $6,918.31 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,467.37 / $8,511.38
| Facility | | $1,023.29 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $346.74 / $501.19
| Professional | | $218.78 | $346.74 | $501.19 |