- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,248.07 / $7,943.28
| Facility | | $1,380.38 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,230.27 / $3,235.94
| Professional | | $794.33 | $1,230.27 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,290.87 / $31,622.78
| Facility | | $1,380.38 | $2,290.87 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,995.26 / $2,344.23
| Professional | | $1,778.28 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,748.98 / $34,673.69
| Facility | | $7,413.10 | $11,748.98 | $34,673.69 |