- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,981.07 / $7,943.28
| Facility | | $1,318.26 | $3,981.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $3,715.35
| Professional | | $776.25 | $1,202.26 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,238.72 / $8,912.51
| Facility | | $1,318.26 | $2,238.72 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,290.87
| Professional | | $1,698.24 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |