- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,981.07 / $6,760.83
| Facility | | $1,778.28 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,230.27 / $3,890.45
| Professional | | $741.31 | $1,230.27 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,786.30 / $11,748.98
| Facility | | $1,479.11 | $4,786.30 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $2,691.53
| Professional | | $2,041.74 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,912.51 / $12,589.25
| Facility | | $6,025.60 | $8,912.51 | $12,589.25 |