- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,128.61 / $8,912.51
| Facility | | $1,318.26 | $5,128.61 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,456.54 / $8,912.51
| Professional | | $3,019.95 | $6,456.54 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,549.93 / $17,378.01
| Facility | | $4,570.88 | $9,549.93 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $691.83 / $977.24
| Professional | | $549.54 | $691.83 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $2,691.53
| Facility | | $676.08 | $1,479.11 | $2,691.53 |