- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,888.44 / $12,302.69
| Facility | | $3,311.31 | $5,888.44 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $2,398.83 / $10,964.78
| Facility | | $588.84 | $2,398.83 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Professional | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $1,995.26
| Professional | | $1,380.38 | $1,659.59 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $446.68 / $691.83
| Professional | | $354.81 | $446.68 | $691.83 |