- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.43 / $1,461.79 / $20,547.79
| Professional | | $1,169.43 | $1,461.79 | $20,547.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $931.48 / $1,507.31 / $1,665.14
| Facility | | $931.48 | $1,507.31 | $1,665.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.44 / $2,578.44 / $28,868.39
| Professional | | $2,578.44 | $2,578.44 | $28,868.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.00 / $1,137.00 / $1,137.00
| Facility | | $1,137.00 | $1,137.00 | $1,137.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.00 / $8,755.61 / $14,736.90
| Professional | | $1,064.00 | $8,755.61 | $14,736.90 |