- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,762.47 / $16,595.87
| Facility | | $3,801.89 | $7,762.47 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $1,288.25 / $3,311.31
| Professional | | $346.74 | $1,288.25 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $371.54 / $676.08
| Facility | | $223.87 | $371.54 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- 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
- $354.81 / $1,202.26 / $3,548.13
| Facility | | $354.81 | $1,202.26 | $3,548.13 |