- 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
- $630.96 / $2,398.83 / $10,964.78
| Facility | | $630.96 | $2,398.83 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,137.96
| Professional | | $1,479.11 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $478.63 / $741.31
| Professional | | $380.19 | $478.63 | $741.31 |