- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,370.32 / $13,803.84
| Facility | | $1,905.46 | $5,370.32 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,380.38 / $2,754.23
| Professional | | $794.33 | $1,380.38 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,311.31 / $13,182.57
| Facility | | $1,548.82 | $3,311.31 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,570.40 / $2,951.21
| Professional | | $1,698.24 | $2,570.40 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $14,125.38
| Facility | | $4,365.16 | $7,079.46 | $14,125.38 |