- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,630.78 / $8,709.64
| Facility | | $1,380.38 | $3,630.78 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $5,248.07
| Professional | | $1,584.89 | $1,905.46 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $758.58 / $1,949.84
| Facility | | $173.78 | $758.58 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Facility | | $10,232.93 | $10,232.93 | $10,232.93 |