- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $7,943.28 / $16,595.87
| Facility | | $776.25 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $3,715.35 / $7,079.46
| Professional | | $131.83 | $3,715.35 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,258.93 / $2,238.72
| Facility | | $562.34 | $1,258.93 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,890.45 / $7,762.47
| Facility | | $1,122.02 | $3,890.45 | $7,762.47 |