- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $5,888.44
| Facility | | $1,698.24 | $2,511.89 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,466.84 / $5,888.44
| Professional | | $3,981.07 | $4,466.84 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $7,762.47 / $9,772.37
| Professional | | $3,162.28 | $7,762.47 | $9,772.37 |
- 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
- $3,890.45 / $4,897.79 / $8,709.64
| Professional | | $3,890.45 | $4,897.79 | $8,709.64 |