- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $2,511.89
| Facility | | $1,258.93 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $1,621.81
| Professional | | $933.25 | $1,071.52 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,584.89 / $1,905.46
| Professional | | $870.96 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,073.80 / $11,748.98
| Facility | | $1,548.82 | $4,073.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,318.26 / $1,905.46
| Professional | | $954.99 | $1,318.26 | $1,905.46 |