- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,235.94 / $10,715.19
| Facility | | $1,513.56 | $3,235.94 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $1,000.00 / $1,513.56
| Professional | | $199.53 | $1,000.00 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,513.56 / $1,905.46
| Facility | | $954.99 | $1,513.56 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |