- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,094.78 / $4,212.99 / $15,356.50
| Facility | | $3,094.78 | $4,212.99 | $15,356.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.76 / $3,474.33 / $3,795.48
| Professional | | $1,751.76 | $3,474.33 | $3,795.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $2,919.60
| Facility | | $2,919.60 | $2,919.60 | $2,919.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.74 / $1,897.74 / $1,897.74
| Facility | | $1,897.74 | $1,897.74 | $1,897.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $4,087.44
| Professional | | $1,226.23 | $1,751.76 | $4,087.44 |