- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $5,248.07 / $7,943.28
| Facility | | $1,258.93 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $870.96 / $3,467.37
| Professional | | $524.81 | $870.96 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,888.44 / $13,182.57
| Facility | | $1,380.38 | $5,888.44 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $2,290.87
| Professional | | $1,548.82 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $10,000.00 / $14,125.38
| Facility | | $6,918.31 | $10,000.00 | $14,125.38 |