- 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
- $1,202.26 / $2,187.76 / $2,398.83
| Professional | | $1,202.26 | $2,187.76 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $9,772.37 / $11,481.54
| Facility | | $0.02 | $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
- $1,905.46 / $2,691.53 / $4,168.69
| Professional | | $1,905.46 | $2,691.53 | $4,168.69 |