- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $4,677.35
| Facility | | $3,467.37 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $2,818.38 / $6,165.95
| Professional | | $186.21 | $2,818.38 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $10,471.29 / $12,589.25
| Facility | | $5,754.40 | $10,471.29 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,025.60 / $12,589.25
| Facility | | $1,230.27 | $6,025.60 | $12,589.25 |