- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,244.36 / $16,218.10
| Facility | | $3,235.94 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $208.93 / $851.14
| Professional | | $97.72 | $208.93 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $275.42 / $758.58
| Professional | | $97.72 | $275.42 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $229.09 / $831.76
| Professional | | $89.13 | $229.09 | $831.76 |