- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,073.80 / $6,456.54
| Facility | | $1,412.54 | $4,073.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $537.03 / $616.60
| Professional | | $316.23 | $537.03 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,466.84 / $9,549.93
| Professional | | $2,290.87 | $4,466.84 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,230.27
| Professional | | $575.44 | $602.56 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $16,218.10 / $35,481.34
| Facility | | $2,344.23 | $16,218.10 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $707.95 / $1,513.56
| Professional | | $467.74 | $707.95 | $1,513.56 |