- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $4,570.88 / $7,079.46
| Facility | | $954.99 | $4,570.88 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $933.25 / $1,949.84
| Professional | | $575.44 | $933.25 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,370.32 / $10,964.78
| Facility | | $1,122.02 | $5,370.32 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,513.56 / $2,238.72
| Professional | | $1,380.38 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,128.31 / $10,964.78
| Facility | | $4,897.79 | $8,128.31 | $10,964.78 |