- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,623.41 / $16,595.87
| Facility | | $1,621.81 | $5,623.41 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $630.96 / $6,309.57
| Professional | | $588.84 | $630.96 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $794.33 / $1,174.90
| Facility | | $630.96 | $794.33 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Professional | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $870.96
| Facility | | $331.13 | $331.13 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $630.96 / $758.58
| Professional | | $602.56 | $630.96 | $758.58 |