- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,365.16 / $4,897.79
| Facility | | $1,096.48 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $2,511.89
| Professional | | $1,096.48 | $1,096.48 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $11,748.98
| Facility | | $1,548.82 | $1,819.70 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |