- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $5,011.87
| Facility | | $2,089.30 | $2,884.03 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,513.56 / $6,606.93
| Professional | | $537.03 | $1,513.56 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $9,120.11 / $16,595.87
| Facility | | $3,467.37 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $1,778.28
| Professional | | $831.76 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,288.25 / $2,041.74
| Facility | | $199.53 | $1,288.25 | $2,041.74 |