- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $5,888.44
| Facility | | $2,398.83 | $2,884.03 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $251.19 / $549.54
| Professional | | $245.47 | $251.19 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $436.52 / $1,122.02
| Facility | | $245.47 | $436.52 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $1,737.80 / $4,365.16
| Facility | | $407.38 | $1,737.80 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $257.04 / $6,025.60
| Professional | | $245.47 | $257.04 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,862.09 / $3,467.37
| Facility | | $380.19 | $1,862.09 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $53.70 / $53.70
| Professional | | $53.70 | $53.70 | $53.70 |