- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,531.87 / $4,403.24
| Facility | | $2,201.62 | $2,531.87 | $4,403.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,531.87 / $2,531.87 / $2,531.87
| Professional | | $2,531.87 | $2,531.87 | $2,531.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.51 / $9.11 / $12.26
| Facility | | $7.51 | $9.11 | $12.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,731.57 / $1,860.37 / $6,904.89
| Facility | | $1,731.57 | $1,860.37 | $6,904.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $2,529.63 / $3,162.03
| Professional | | $2,529.63 | $2,529.63 | $3,162.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $924.68 / $1,320.97
| Professional | | $924.68 | $924.68 | $1,320.97 |