- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,365.16 / $7,413.10
| Facility | | $1,445.44 | $4,365.16 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $1,380.38 / $3,801.89
| Professional | | $263.03 | $1,380.38 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,089.30 / $3,548.13
| Facility | | $758.58 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $1,479.11 / $2,511.89
| Facility | | $177.83 | $1,479.11 | $2,511.89 |