- 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
- $676.08 / $4,265.80 / $16,595.87
| Facility | | $676.08 | $4,265.80 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Professional | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $2,290.87
| Professional | | $1,584.89 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $512.86 / $794.33
| Professional | | $398.11 | $512.86 | $794.33 |