- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,786.30 / $8,709.64
| Facility | | $1,659.59 | $4,786.30 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,412.54 / $3,090.30
| Professional | | $870.96 | $1,412.54 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,570.40 / $17,782.79
| Facility | | $1,380.38 | $2,570.40 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $2,818.38
| Professional | | $1,949.84 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,549.93 / $19,498.45
| Facility | | $5,495.41 | $9,549.93 | $19,498.45 |