- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,466.84 / $6,760.83
| Facility | | $2,398.83 | $4,466.84 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $446.68 / $1,047.13
| Professional | | $363.08 | $446.68 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $389.05 / $645.65
| Professional | | $295.12 | $389.05 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $512.86 / $794.33
| Professional | | $181.97 | $512.86 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $13,489.63
| Facility | | $3,715.35 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $489.78 / $776.25
| Professional | | $338.84 | $489.78 | $776.25 |