- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $11,481.54 / $28,183.83
| Facility | | $4,677.35 | $11,481.54 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $3,801.89
| Professional | | $1,258.93 | $1,412.54 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $707.95 / $954.99
| Facility | | $501.19 | $707.95 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $50.12 / $75.86
| Professional | | $32.36 | $50.12 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,258.93 / $5,754.40
| Facility | | $707.95 | $1,258.93 | $5,754.40 |