- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $7,244.36 / $16,595.87
| Facility | | $3,311.31 | $7,244.36 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $524.81 / $2,398.83
| Professional | | $257.04 | $524.81 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.50 / $2,290.87 / $6,165.95
| Facility | | $95.50 | $2,290.87 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $436.52 / $2,511.89
| Professional | | $398.11 | $436.52 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,890.45 / $7,762.47
| Facility | | $1,122.02 | $3,890.45 | $7,762.47 |