- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,165.95 / $12,589.25
| Facility | | $2,187.76 | $6,165.95 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $630.96 / $2,511.89
| Professional | | $354.81 | $630.96 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,709.64 / $16,982.44
| Facility | | $6,606.93 | $8,709.64 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,230.27 / $4,365.16
| Facility | | $302.00 | $1,230.27 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $1,230.27 / $4,466.84
| Facility | | $309.03 | $1,230.27 | $4,466.84 |