- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,456.54 / $8,128.31
| Facility | | $4,897.79 | $6,456.54 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $478.63 / $1,202.26
| Professional | | $416.87 | $478.63 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Facility | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $467.74 / $851.14
| Professional | | $363.08 | $467.74 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $501.19
| Facility | | $144.54 | $144.54 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $478.63 / $758.58
| Professional | | $380.19 | $478.63 | $758.58 |