- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $4,365.16
| Facility | | $933.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,905.46 / $2,691.53
| Professional | | $1,047.13 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,413.10 / $14,125.38
| Facility | | $4,265.80 | $7,413.10 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,548.13 / $10,964.78
| Facility | | $1,023.29 | $3,548.13 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,380.38 / $2,818.38
| Professional | | $524.81 | $1,380.38 | $2,818.38 |