- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $5,011.87
| Facility | | $1,584.89 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $660.69 / $2,041.74
| Professional | | $158.49 | $660.69 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $9,120.11 / $16,595.87
| Facility | | $3,467.37 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $691.83 / $1,047.13
| Professional | | $354.81 | $691.83 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,949.84 / $6,309.57
| Facility | | $724.44 | $1,949.84 | $6,309.57 |