- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,162.28 / $6,606.93
| Facility | | $1,023.29 | $3,162.28 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $2,511.89
| Professional | | $1,659.59 | $2,137.96 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,698.24 / $21,379.62
| Facility | | $389.05 | $1,698.24 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $4,073.80
| Professional | | $1,905.46 | $2,454.71 | $4,073.80 |