- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,025.60 / $13,489.63
| Facility | | $3,890.45 | $6,025.60 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $346.74 / $416.87
| Professional | | $269.15 | $346.74 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,162.28 / $11,748.98
| Facility | | $2,137.96 | $3,162.28 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $616.60 / $758.58
| Professional | | $239.88 | $616.60 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,677.35 / $10,232.93
| Facility | | $1,905.46 | $4,677.35 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $549.54 / $1,071.52
| Professional | | $346.74 | $549.54 | $1,071.52 |