- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $12,589.25 / $20,892.96
| Facility | | $870.96 | $12,589.25 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Professional | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,981.07 / $16,595.87
| Facility | | $2,884.03 | $3,981.07 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $9,120.11 / $19,498.45
| Facility | | $1,348.96 | $9,120.11 | $19,498.45 |