- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,073.80 / $5,623.41
| Facility | | $3,467.37 | $4,073.80 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $25.12 / $549.54
| Professional | | $25.12 | $25.12 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $1,148.15 / $2,511.89
| Facility | | $407.38 | $1,148.15 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $758.58
| Professional | | $501.19 | $501.19 | $758.58 |