- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,630.27 / $6,606.93
| Facility | | $1,288.25 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,778.28 / $3,235.94
| Professional | | $467.74 | $1,778.28 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,370.32 / $8,912.51
| Facility | | $3,467.37 | $5,370.32 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $1,318.26 / $2,691.53
| Facility | | $223.87 | $1,318.26 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,318.26 / $2,630.27
| Facility | | $371.54 | $1,318.26 | $2,630.27 |