- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,981.07 / $6,760.83
| Facility | | $1,202.26 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,023.29 / $2,398.83
| Professional | | $630.96 | $1,023.29 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,905.46 / $8,912.51
| Facility | | $1,071.52 | $1,905.46 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $2,089.30
| Professional | | $1,445.44 | $1,737.80 | $2,089.30 |
- 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 |