- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,041.74 / $4,570.88
| Facility | | $891.25 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,467.37 / $5,495.41
| Professional | | $1,148.15 | $3,467.37 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $20,417.38 / $30,902.95
| Facility | | $10,715.19 | $20,417.38 | $30,902.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $9,772.37 / $24,547.09
| Facility | | $1,202.26 | $9,772.37 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,445.44 / $2,691.53
| Professional | | $933.25 | $1,445.44 | $2,691.53 |