- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $10,964.78
| Facility | | $2,398.83 | $3,235.94 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $446.68 / $851.14
| Professional | | $269.15 | $446.68 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $416.87 / $758.58
| Professional | | $269.15 | $416.87 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $524.81 / $977.24
| Professional | | $354.81 | $524.81 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $457.09 / $891.25
| Professional | | $302.00 | $457.09 | $891.25 |