- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,890.45 / $7,943.28
| Facility | | $1,737.80 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $870.96 / $4,677.35
| Professional | | $173.78 | $870.96 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,096.48 / $1,995.26
| Facility | | $416.87 | $1,096.48 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $257.04 / $416.87
| Professional | | $199.53 | $257.04 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,548.82 / $3,235.94
| Facility | | $524.81 | $1,548.82 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Professional | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,258.93 / $3,235.94
| Facility | | $707.95 | $1,258.93 | $3,235.94 |