- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $5,248.07 / $7,943.28
| Facility | | $1,479.11 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $2,238.72
| Professional | | $870.96 | $1,288.25 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,137.96 / $9,772.37
| Facility | | $1,122.02 | $2,137.96 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $2,570.40
| Professional | | $1,621.81 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |