- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,786.30 / $7,079.46
| Facility | | $1,047.13 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $2,238.72
| Professional | | $602.56 | $933.25 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,737.80 / $17,782.79
| Facility | | $1,047.13 | $1,737.80 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $1,778.28
| Professional | | $1,348.96 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,549.93 / $19,498.45
| Facility | | $5,495.41 | $9,549.93 | $19,498.45 |