- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $5,370.32 / $7,943.28
| Facility | | $1,096.48 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,148.15 / $2,818.38
| Professional | | $691.83 | $1,148.15 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,737.80 / $11,481.54
| Facility | | $1,071.52 | $1,737.80 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,621.81 / $2,290.87
| Professional | | $1,513.56 | $1,621.81 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $21,379.62
| Facility | | $8,511.38 | $11,748.98 | $21,379.62 |