- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,248.07 / $8,511.38
| Facility | | $2,511.89 | $5,248.07 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,570.88 / $5,623.41
| Professional | | $4,265.80 | $4,570.88 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $691.83 / $776.25
| Professional | | $602.56 | $691.83 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,235.94 / $11,220.18
| Facility | | $1,174.90 | $3,235.94 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,818.38 / $10,471.29
| Facility | | $1,380.38 | $2,818.38 | $10,471.29 |