- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,162.28 / $6,760.83
| Facility | | $1,479.11 | $3,162.28 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,445.44 / $2,754.23
| Professional | | $891.25 | $1,445.44 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,365.16 / $16,218.10
| Facility | | $1,412.54 | $4,365.16 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,995.26 / $2,884.03
| Professional | | $1,905.46 | $1,995.26 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $15,488.17
| Facility | | $4,365.16 | $7,079.46 | $15,488.17 |