- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,235.94 / $6,760.83
| Facility | | $1,380.38 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,318.26 / $4,677.35
| Professional | | $851.14 | $1,318.26 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,090.30 / $10,232.93
| Facility | | $1,380.38 | $3,090.30 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $2,884.03
| Professional | | $1,905.46 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,762.47 / $10,715.19
| Facility | | $4,786.30 | $7,762.47 | $10,715.19 |