- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,981.07 / $6,760.83
| Facility | | $1,584.89 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $2,630.27
| Professional | | $851.14 | $1,348.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,454.71 / $8,912.51
| Facility | | $1,348.96 | $2,454.71 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $2,691.53
| Professional | | $1,862.09 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |