- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,456.54 / $13,803.84
| Facility | | $3,630.78 | $6,456.54 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,412.54
| Professional | | $1,047.13 | $1,047.13 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $3,235.94 / $9,120.11
| Facility | | $512.86 | $3,235.94 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,513.56 / $4,265.80
| Professional | | $676.08 | $1,513.56 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $7,762.47 / $18,197.01
| Facility | | $3,162.28 | $7,762.47 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $1,071.52 / $2,511.89
| Professional | | $338.84 | $1,071.52 | $2,511.89 |