- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,637.68 / $2,449.87 / $9,815.04
| Facility | | $1,637.68 | $2,449.87 | $9,815.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.94 / $948.80 / $1,143.91
| Professional | | $753.94 | $948.80 | $1,143.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.01 / $1,117.90 / $1,547.53
| Professional | | $866.01 | $1,117.90 | $1,547.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,104.64 / $6,772.50 / $14,282.34
| Facility | | $6,104.64 | $6,772.50 | $14,282.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.77 / $1,141.49 / $2,486.88
| Professional | | $865.77 | $1,141.49 | $2,486.88 |