- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,801.89 / $12,589.25
| Facility | | $741.31 | $3,801.89 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $6,760.83
| Facility | | $2,691.53 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $295.12 / $630.96
| Facility | | $91.20 | $295.12 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $602.56 / $870.96
| Professional | | $204.17 | $602.56 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $6,309.57
| Facility | | $1,148.15 | $1,819.70 | $6,309.57 |