- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,801.89 / $6,606.93
| Facility | | $1,288.25 | $3,801.89 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $6,309.57
| Professional | | $1,819.70 | $1,819.70 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,011.87 / $8,128.31
| Facility | | $3,162.28 | $5,011.87 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $602.56 / $1,659.59
| Facility | | $89.13 | $602.56 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $616.60 / $1,659.59
| Facility | | $138.04 | $616.60 | $1,659.59 |