- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $5,011.87
| Facility | | $1,698.24 | $2,511.89 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,168.69 / $5,011.87
| Professional | | $3,019.95 | $4,168.69 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $7,079.46 / $9,120.11
| Professional | | $2,951.21 | $7,079.46 | $9,120.11 |
- 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
- $3,388.44 / $4,365.16 / $8,128.31
| Professional | | $3,388.44 | $4,365.16 | $8,128.31 |