- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $16,218.10
| Facility | | $7,244.36 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $562.34 / $1,174.90
| Professional | | $524.81 | $562.34 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $588.84 / $707.95
| Professional | | $467.74 | $588.84 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $602.56 / $1,096.48
| Professional | | $478.63 | $602.56 | $1,096.48 |