- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,120.11 / $16,595.87
| Facility | | $6,760.83 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $346.74 / $398.11
| Professional | | $251.19 | $346.74 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $407.38 / $707.95
| Facility | | $338.84 | $407.38 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $13,182.57 / $23,988.33
| Facility | | $5,128.61 | $13,182.57 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $478.63 / $831.76
| Professional | | $338.84 | $478.63 | $831.76 |