- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,981.07 / $6,760.83
| Facility | | $1,380.38 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $3,801.89
| Professional | | $776.25 | $1,122.02 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,290.87 / $17,782.79
| Facility | | $1,122.02 | $2,290.87 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $2,344.23
| Professional | | $1,230.27 | $1,995.26 | $2,344.23 |
- 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 |