- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,659.59 / $2,511.89
| Facility | | $870.96 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $5,011.87 / $11,748.98
| Professional | | $380.19 | $5,011.87 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $16,218.10
| Facility | | $11,748.98 | $11,748.98 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $18,197.01
| Facility | | $3,715.35 | $7,762.47 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $794.33 / $2,691.53
| Professional | | $416.87 | $794.33 | $2,691.53 |