- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,511.89 / $6,918.31
| Facility | | $1,122.02 | $2,511.89 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,905.46 / $3,388.44
| Professional | | $1,122.02 | $1,905.46 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $8,511.38 / $10,471.29
| Facility | | $3,090.30 | $8,511.38 | $10,471.29 |
- 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
- $1,621.81 / $2,344.23 / $3,630.78
| Professional | | $1,621.81 | $2,344.23 | $3,630.78 |