- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $4,466.84 / $10,232.93
| Facility | | $2,137.96 | $4,466.84 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $4,466.84
| Professional | | $977.24 | $977.24 | $4,466.84 |
- 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
- $177.83 / $776.25 / $1,122.02
| Professional | | $177.83 | $776.25 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,995.26 / $6,309.57
| Facility | | $724.44 | $1,995.26 | $6,309.57 |