- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $6,760.83
| Facility | | $1,047.13 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,202.26 / $2,398.83
| Professional | | $707.95 | $1,202.26 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,570.88 / $16,218.10
| Facility | | $1,047.13 | $4,570.88 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,137.96
| Professional | | $1,445.44 | $1,698.24 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,715.19 / $15,488.17
| Facility | | $7,413.10 | $10,715.19 | $15,488.17 |