- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $4,786.30 / $7,079.46
| Facility | | $1,949.84 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,698.24 / $4,365.16
| Professional | | $1,148.15 | $1,698.24 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,235.94 / $44,668.36
| Facility | | $1,862.09 | $3,235.94 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,951.21 / $3,235.94
| Professional | | $2,691.53 | $2,951.21 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $46,773.51
| Facility | | $8,511.38 | $13,489.63 | $46,773.51 |