- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,235.94 / $6,760.83
| Facility | | $1,584.89 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,380.38 / $3,311.31
| Professional | | $891.25 | $1,380.38 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,862.09 / $8,317.64
| Facility | | $794.33 | $1,862.09 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,238.72 / $2,691.53
| Professional | | $1,949.84 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,511.38 / $11,748.98
| Facility | | $5,128.61 | $8,511.38 | $11,748.98 |