- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $4,677.35
| Facility | | $1,698.24 | $2,511.89 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,467.37 / $4,786.30
| Professional | | $2,884.03 | $3,467.37 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,011.87 / $6,760.83
| Professional | | $1,202.26 | $5,011.87 | $6,760.83 |
- 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
- $2,951.21 / $3,467.37 / $6,456.54
| Professional | | $2,951.21 | $3,467.37 | $6,456.54 |