- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,801.89 / $6,760.83
| Facility | | $1,122.02 | $3,801.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,096.48 / $2,187.76
| Professional | | $676.08 | $1,096.48 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,862.09 / $15,135.61
| Facility | | $933.25 | $1,862.09 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $2,290.87
| Professional | | $1,445.44 | $1,862.09 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,413.10 / $19,498.45
| Facility | | $4,365.16 | $7,413.10 | $19,498.45 |