- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,248.07 / $7,943.28
| Facility | | $1,584.89 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,445.44 / $3,981.07
| Professional | | $954.99 | $1,445.44 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,290.87 / $9,772.37
| Facility | | $1,318.26 | $2,290.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,344.23 / $2,754.23
| Professional | | $2,089.30 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |