- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,570.40 / $6,760.83
| Facility | | $1,148.15 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,318.26 / $3,311.31
| Professional | | $758.58 | $1,318.26 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,786.30 / $13,489.63
| Facility | | $1,148.15 | $4,786.30 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,344.23
| Professional | | $1,548.82 | $1,819.70 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $8,511.38 / $14,125.38
| Facility | | $5,495.41 | $8,511.38 | $14,125.38 |