- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,762.47 / $16,595.87
| Facility | | $3,801.89 | $7,762.47 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Professional | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $269.15 / $467.74
| Facility | | $147.91 | $269.15 | $467.74 |
- 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 |