- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,025.60 / $7,585.78
| Facility | | $2,187.76 | $6,025.60 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $380.19 / $912.01
| Professional | | $288.40 | $380.19 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $295.12 / $501.19
| Professional | | $223.87 | $295.12 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $407.38 / $616.60
| Professional | | $151.36 | $407.38 | $616.60 |
- 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
- $263.03 / $407.38 / $562.34
| Professional | | $263.03 | $407.38 | $562.34 |