- 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 / $2,754.23
| Professional | | $602.56 | $933.25 | $2,754.23 |
- 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
- $1,318.26 / $1,513.56 / $1,778.28
| Professional | | $1,318.26 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $19,498.45
| Facility | | $7,413.10 | $11,481.54 | $19,498.45 |