- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $7,244.36
| Facility | | $1,698.24 | $2,884.03 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,202.26 / $3,388.44
| Professional | | $389.05 | $1,202.26 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $5,623.41
| Facility | | $1,905.46 | $2,884.03 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,148.15 / $2,818.38
| Professional | | $380.19 | $1,148.15 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $691.83 / $1,819.70
| Facility | | $275.42 | $691.83 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,890.45 / $3,890.45
| Professional | | $1,862.09 | $3,890.45 | $3,890.45 |