- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,762.47 / $16,595.87
| Facility | | $3,801.89 | $7,762.47 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $9,120.11
| Professional | | $3,801.89 | $3,801.89 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,398.83 / $4,265.80
| Facility | | $1,348.96 | $2,398.83 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,202.26 / $3,548.13
| Facility | | $380.19 | $1,202.26 | $3,548.13 |