- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $7,943.28
| Facility | | $1,698.24 | $2,511.89 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,623.41 / $7,413.10
| Professional | | $5,248.07 | $5,623.41 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $9,120.11 / $10,471.29
| Professional | | $3,388.44 | $9,120.11 | $10,471.29 |
- 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
- $5,011.87 / $6,309.57 / $11,748.98
| Professional | | $5,011.87 | $6,309.57 | $11,748.98 |