- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,413.10 / $11,748.98
| Facility | | $4,466.84 | $7,413.10 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $257.04 / $398.11
| Professional | | $190.55 | $257.04 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $389.05 / $389.05
| Professional | | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $295.12 / $602.56
| Professional | | $218.78 | $295.12 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,623.41 / $10,471.29
| Facility | | $1,584.89 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $288.40 / $501.19
| Professional | | $213.80 | $288.40 | $501.19 |