- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,248.07 / $7,943.28
| Facility | | $1,348.96 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,621.81 / $3,388.44
| Professional | | $912.01 | $1,621.81 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,073.80 / $13,803.84
| Facility | | $1,548.82 | $4,073.80 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,187.76 / $3,090.30
| Professional | | $2,041.74 | $2,187.76 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $14,125.38
| Facility | | $4,365.16 | $7,079.46 | $14,125.38 |