- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,570.40 / $6,760.83
| Facility | | $1,380.38 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $912.01 / $1,548.82
| Professional | | $562.34 | $912.01 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,454.71 / $10,000.00
| Facility | | $954.99 | $2,454.71 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $1,995.26
| Professional | | $1,122.02 | $1,548.82 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,128.31 / $10,964.78
| Facility | | $5,128.61 | $8,128.31 | $10,964.78 |