- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $48,977.88
| Facility | | $3,715.35 | $6,025.60 | $48,977.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $4,570.88
| Professional | | $1,258.93 | $1,479.11 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,548.82 / $2,630.27
| Professional | | $1,071.52 | $1,548.82 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,511.89
| Facility | | $1,995.26 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $2,454.71
| Professional | | $1,202.26 | $1,479.11 | $2,454.71 |