- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $10,964.78
| Facility | | $10,964.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $346.74
| Professional | | $245.47 | $245.47 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,137.96
| Professional | | $1,479.11 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $512.86 / $1,047.13
| Professional | | $371.54 | $512.86 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $6,456.54 / $8,317.64
| Facility | | $1,995.26 | $6,456.54 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $436.52 / $630.96
| Professional | | $331.13 | $436.52 | $630.96 |