- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $6,456.54 / $11,481.54
| Facility | | $1,258.93 | $6,456.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,445.44 / $4,677.35
| Professional | | $891.25 | $1,445.44 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $12,589.25 / $44,668.36
| Facility | | $1,949.84 | $12,589.25 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,344.23 / $8,912.51
| Professional | | $2,238.72 | $2,344.23 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $19,054.61 / $47,863.01
| Facility | | $9,772.37 | $19,054.61 | $47,863.01 |