- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,235.94 / $6,760.83
| Facility | | $1,288.25 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,318.26 / $3,019.95
| Professional | | $794.33 | $1,318.26 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,168.69 / $16,218.10
| Facility | | $1,258.93 | $4,168.69 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,187.76
| Professional | | $1,318.26 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $17,378.01
| Facility | | $4,365.16 | $7,079.46 | $17,378.01 |