- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,339.34 / $1,823.28 / $6,645.91
| Facility | | $1,339.34 | $1,823.28 | $6,645.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.12 / $1,503.60 / $1,642.59
| Professional | | $758.12 | $1,503.60 | $1,642.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.87 / $986.55 / $1,095.07
| Professional | | $896.87 | $986.55 | $1,095.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $1,263.53
| Facility | | $1,263.53 | $1,263.53 | $1,263.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.29 / $8,924.87 / $9,594.03
| Facility | | $821.29 | $8,924.87 | $9,594.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $720.34 / $1,642.59
| Professional | | $530.67 | $720.34 | $1,642.59 |