- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,318.26 / $3,890.45
| Facility | | $676.08 | $1,318.26 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,174.90 / $3,715.35
| Professional | | $549.54 | $1,174.90 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,897.79 / $7,079.46
| Facility | | $2,884.03 | $4,897.79 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,754.23 / $6,606.93
| Facility | | $831.76 | $2,754.23 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $190.55
| Professional | | $186.21 | $186.21 | $190.55 |