- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,466.84 / $12,882.50
| Facility | | $2,570.40 | $4,466.84 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $616.60
| Professional | | $512.86 | $512.86 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $630.96 / $831.76
| Professional | | $141.25 | $630.96 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,096.48 / $1,096.48
| Facility | | $977.24 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $436.52 / $758.58
| Professional | | $354.81 | $436.52 | $758.58 |