- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,405.80 / $21,144.87 / $33,649.15
| Facility | | $13,405.80 | $21,144.87 | $33,649.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.80 / $520.92 / $640.67
| Professional | | $380.80 | $520.92 | $640.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.25 / $773.21 / $5,882.00
| Facility | | $436.25 | $773.21 | $5,882.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.08 / $512.58 / $4,568.99
| Professional | | $361.08 | $512.58 | $4,568.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.47 / $456.53 / $676.52
| Professional | | $344.47 | $456.53 | $676.52 |