- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $6,606.93
| Facility | | $933.25 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,318.26 / $1,412.54
| Professional | | $1,148.15 | $1,318.26 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $9,549.93 / $14,125.38
| Facility | | $5,623.41 | $9,549.93 | $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
- $1,148.15 / $1,698.24 / $3,388.44
| Professional | | $1,148.15 | $1,698.24 | $3,388.44 |