- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,981.07 / $6,760.83
| Facility | | $1,659.59 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $3,981.07
| Professional | | $977.24 | $1,479.11 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,691.53 / $7,413.10
| Facility | | $1,288.25 | $2,691.53 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $2,818.38
| Professional | | $2,041.74 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,413.10 / $19,498.45
| Facility | | $4,365.16 | $7,413.10 | $19,498.45 |