- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,888.44 / $10,715.19
| Facility | | $3,311.31 | $5,888.44 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $758.58 / $6,165.95
| Professional | | $95.50 | $758.58 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $4,677.35
| Facility | | $1,819.70 | $3,019.95 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,011.87 / $8,511.38
| Facility | | $2,089.30 | $5,011.87 | $8,511.38 |