- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,819.70 / $2,511.89
| Facility | | $1,230.27 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $2,754.23
| Professional | | $1,230.27 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,388.44 / $13,489.63
| Facility | | $2,137.96 | $3,388.44 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,454.71 / $3,548.13
| Professional | | $1,584.89 | $2,454.71 | $3,548.13 |