- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,981.07 / $8,709.64
| Facility | | $1,318.26 | $3,981.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $977.24 / $7,762.47
| Professional | | $346.74 | $977.24 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $17,782.79
| Facility | | $2,570.40 | $4,677.35 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,754.40 / $12,302.69
| Facility | | $2,630.27 | $5,754.40 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | | $223.87 | $223.87 | $223.87 |