- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $6,025.60 / $7,943.28
| Facility | | $1,380.38 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,380.38 / $3,019.95
| Professional | | $851.14 | $1,380.38 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $8,128.31 / $14,454.40
| Facility | | $1,819.70 | $8,128.31 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $3,467.37
| Professional | | $1,995.26 | $2,344.23 | $3,467.37 |
- 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 |