- 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
- $1,698.24 / $2,238.72 / $2,630.27
| Professional | | $1,698.24 | $2,238.72 | $2,630.27 |
- 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
- $1,995.26 / $2,570.40 / $4,168.69
| Professional | | $1,995.26 | $2,570.40 | $4,168.69 |