- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,570.40 / $4,897.79
| Facility | | $891.25 | $2,570.40 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $758.58 / $1,995.26
| Professional | | $85.11 | $758.58 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,762.47 / $11,220.18
| Facility | | $4,570.88 | $7,762.47 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Facility | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $676.08 / $1,202.26
| Facility | | $489.78 | $676.08 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,677.35 / $11,748.98
| Facility | | $1,148.15 | $4,677.35 | $11,748.98 |