- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $11,748.98
| Facility | | $4,466.84 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $5,011.87
| Professional | | $831.76 | $831.76 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $954.99 / $3,630.78
| Professional | | $616.60 | $954.99 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $891.25
| Professional | | $758.58 | $758.58 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |