- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $6,025.60 / $7,943.28
| Facility | | $1,258.93 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $2,951.21
| Professional | | $794.33 | $1,288.25 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $8,128.31 / $14,454.40
| Facility | | $1,584.89 | $8,128.31 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $3,162.28
| Professional | | $1,862.09 | $2,089.30 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,481.54 / $15,135.61
| Facility | | $7,244.36 | $11,481.54 | $15,135.61 |