- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,981.07 / $6,760.83
| Facility | | $1,230.27 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $3,715.35
| Professional | | $812.83 | $1,202.26 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,238.72 / $15,848.93
| Facility | | $1,230.27 | $2,238.72 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,995.26 / $2,290.87
| Professional | | $1,737.80 | $1,995.26 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,748.98 / $23,442.29
| Facility | | $7,413.10 | $11,748.98 | $23,442.29 |