- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $6,606.93 / $8,128.31
| Facility | | $1,862.09 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $3,715.35
| Professional | | $1,096.48 | $1,659.59 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,090.30 / $44,668.36
| Facility | | $1,862.09 | $3,090.30 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $3,162.28
| Professional | | $2,398.83 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,218.10 / $46,773.51
| Facility | | $10,471.29 | $16,218.10 | $46,773.51 |