- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,388.44 / $7,943.28
| Facility | | $1,548.82 | $3,388.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $2,691.53
| Professional | | $933.25 | $1,380.38 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,570.40 / $14,454.40
| Facility | | $1,288.25 | $2,570.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,238.72 / $2,630.27
| Professional | | $1,949.84 | $2,238.72 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,413.10 / $15,848.93
| Facility | | $4,365.16 | $7,413.10 | $15,848.93 |