- 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
- $275.42 / $354.81 / $426.58
| Professional | | $275.42 | $354.81 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $6,456.54 / $10,715.19
| Facility | | $3,548.13 | $6,456.54 | $10,715.19 |
- 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
- $331.13 / $501.19 / $741.31
| Professional | | $331.13 | $501.19 | $741.31 |