- 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
- $169.82 / $218.78 / $257.04
| Professional | | $169.82 | $218.78 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,248.07 / $7,413.10
| Facility | | $2,951.21 | $5,248.07 | $7,413.10 |
- 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
- $204.17 / $302.00 / $446.68
| Professional | | $204.17 | $302.00 | $446.68 |