- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,079.46 / $15,135.61
| Facility | | $3,981.07 | $7,079.46 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $2,089.30 / $2,398.83
| Professional | | $912.01 | $2,089.30 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $9,772.37 / $11,481.54
| Facility | | $2,398.83 | $9,772.37 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,570.40 / $3,162.28
| Professional | | $1,778.28 | $2,570.40 | $3,162.28 |