- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $10,232.93 / $28,183.83
| Facility | | $1,202.26 | $10,232.93 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,513.56
| Professional | | $1,202.26 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $75.86
| Professional | | $64.57 | $64.57 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,370.32
| Facility | | $4,265.80 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,071.52 / $6,165.95
| Facility | | $501.19 | $1,071.52 | $6,165.95 |