- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,760.83 / $11,748.98
| Facility | | $4,365.16 | $6,760.83 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $645.65 / $12,302.69
| Professional | | $83.18 | $645.65 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Professional | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $4,677.35
| Facility | | $1,819.70 | $2,818.38 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,548.13 / $7,762.47
| Facility | | $1,778.28 | $3,548.13 | $7,762.47 |