- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $6,760.83
| Facility | | $1,047.13 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,096.48 / $2,691.53
| Professional | | $630.96 | $1,096.48 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,162.28 / $9,549.93
| Facility | | $1,047.13 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,479.11 / $1,995.26
| Professional | | $1,348.96 | $1,479.11 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,762.47 / $10,715.19
| Facility | | $4,786.30 | $7,762.47 | $10,715.19 |