- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,248.07 / $8,709.64
| Facility | | $1,318.26 | $5,248.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $5,888.44 / $8,912.51
| Professional | | $954.99 | $5,888.44 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $12,589.25
| Facility | | $2,454.71 | $3,467.37 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $2,691.53
| Facility | | $676.08 | $1,479.11 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $69.18 / $69.18
| Professional | | $69.18 | $69.18 | $69.18 |