- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,162.28 / $4,570.88
| Facility | | $891.25 | $3,162.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $977.24 / $2,818.38
| Professional | | $912.01 | $977.24 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,073.80 / $9,120.11
| Facility | | $3,467.37 | $4,073.80 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,466.84 / $5,128.61
| Facility | | $1,698.24 | $4,466.84 | $5,128.61 |