- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,235.94 / $6,760.83
| Facility | | $1,548.82 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,659.59 / $3,715.35
| Professional | | $933.25 | $1,659.59 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $7,244.36 / $24,547.09
| Facility | | $1,621.81 | $7,244.36 | $24,547.09 |
- 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
- $7,413.10 / $11,748.98 / $25,118.86
| Facility | | $7,413.10 | $11,748.98 | $25,118.86 |