- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,801.89 / $7,943.28
| Facility | | $1,479.11 | $3,801.89 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,288.25 / $2,884.03
| Professional | | $660.69 | $1,288.25 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,187.76 / $12,589.25
| Facility | | $1,096.48 | $2,187.76 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $2,691.53
| Professional | | $1,479.11 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,964.78 / $15,848.93
| Facility | | $7,413.10 | $10,964.78 | $15,848.93 |