- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $6,025.60
| Facility | | $1,621.81 | $2,187.76 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $1,071.52
| Professional | | $954.99 | $954.99 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,762.47 / $19,054.61
| Facility | | $4,677.35 | $7,762.47 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $3,235.94
| Professional | | $2,454.71 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $2,187.76
| Facility | | $1,047.13 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $1,318.26
| Professional | | $660.69 | $870.96 | $1,318.26 |