- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.50 / $8,477.27 / $20,928.72
| Facility | | $2,007.50 | $8,477.27 | $20,928.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Professional | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.85 / $462.77 / $895.15
| Facility | | $351.85 | $462.77 | $895.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $83.76 / $4,317.00
| Facility | | $47.86 | $83.76 | $4,317.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.62 / $2,034.62 / $2,034.62
| Professional | | $2,034.62 | $2,034.62 | $2,034.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.00 / $1,775.00 / $4,406.00
| Facility | | $1,031.00 | $1,775.00 | $4,406.00 |