- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,248.07 / $7,943.28
| Facility | | $1,202.26 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,659.59 / $3,467.37
| Professional | | $977.24 | $1,659.59 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,715.35 / $12,589.25
| Facility | | $1,698.24 | $3,715.35 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $3,388.44
| Professional | | $2,187.76 | $2,290.87 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $8,511.38 / $13,182.57
| Facility | | $5,495.41 | $8,511.38 | $13,182.57 |