- 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
- $3,548.13 / $3,981.07 / $5,128.61
| Professional | | $3,548.13 | $3,981.07 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,760.83 / $8,709.64
| Professional | | $2,818.38 | $6,760.83 | $8,709.64 |
- 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
- $3,235.94 / $4,265.80 / $7,762.47
| Professional | | $3,235.94 | $4,265.80 | $7,762.47 |