- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,090.30 / $6,760.83
| Facility | | $1,047.13 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,023.29 / $2,290.87
| Professional | | $616.60 | $1,023.29 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,778.28 / $15,135.61
| Facility | | $954.99 | $1,778.28 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $2,290.87
| Professional | | $1,445.44 | $1,778.28 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |