- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,943.28 / $16,595.87
| Facility | | $4,677.35 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $562.34 / $1,862.09
| Professional | | $302.00 | $562.34 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $251.19 / $446.68
| Facility | | $144.54 | $251.19 | $446.68 |
- 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
- $380.19 / $1,202.26 / $3,548.13
| Facility | | $380.19 | $1,202.26 | $3,548.13 |