- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,981.07 / $6,760.83
| Facility | | $1,318.26 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $3,467.37
| Professional | | $776.25 | $1,148.15 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,187.76 / $17,782.79
| Facility | | $1,288.25 | $2,187.76 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,862.09 / $2,238.72
| Professional | | $1,698.24 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $19,498.45
| Facility | | $7,413.10 | $11,481.54 | $19,498.45 |