- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,981.07 / $6,760.83
| Facility | | $1,174.90 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $2,951.21
| Professional | | $707.95 | $1,047.13 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,995.26 / $17,782.79
| Facility | | $1,174.90 | $1,995.26 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,778.28 / $1,995.26
| Professional | | $1,584.89 | $1,778.28 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,549.93 / $19,498.45
| Facility | | $5,495.41 | $9,549.93 | $19,498.45 |