- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $14,125.38 / $26,915.35
| Facility | | $5,248.07 | $14,125.38 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,311.31 / $8,128.31
| Facility | | $2,454.71 | $3,311.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,071.52 / $1,288.25
| Professional | | $1,023.29 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.84 / $30.20 / $891.25
| Facility | | $28.84 | $30.20 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $69.18 / $154.88
| Professional | | $28.18 | $69.18 | $154.88 |