- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $4,786.30 / $10,964.78
| Facility | | $691.83 | $4,786.30 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $691.83
| Professional | | $660.69 | $660.69 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $660.69 / $776.25
| Facility | | $645.65 | $660.69 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $467.74 / $501.19
| Facility | | $436.52 | $467.74 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,548.13 / $6,760.83
| Facility | | $1,023.29 | $3,548.13 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.49 / $13.49 / $13.49
| Professional | | $13.49 | $13.49 | $13.49 |