- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,137.96 / $7,762.47
| Facility | | $1,047.13 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $691.83 / $1,096.48
| Professional | | $295.12 | $691.83 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $60.26 / $85.11
| Professional | | $50.12 | $60.26 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $602.56 / $1,096.48
| Facility | | $295.12 | $602.56 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $1,096.48 / $1,412.54
| Facility | | $229.09 | $1,096.48 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $645.65 / $891.25
| Professional | | $457.09 | $645.65 | $891.25 |