- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,786.30 / $12,882.50
| Facility | | $2,691.53 | $4,786.30 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $3,890.45
| Facility | | $1,174.90 | $1,621.81 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $537.03 / $616.60
| Professional | | $489.78 | $537.03 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $2,089.30 / $6,456.54
| Facility | | $691.83 | $2,089.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $478.63 / $776.25
| Professional | | $323.59 | $478.63 | $776.25 |