- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,801.89 / $6,760.83
| Facility | | $1,621.81 | $3,801.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,479.11 / $4,570.88
| Professional | | $954.99 | $1,479.11 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,754.23 / $17,782.79
| Facility | | $1,621.81 | $2,754.23 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $2,818.38
| Professional | | $2,089.30 | $2,398.83 | $2,818.38 |
- 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 |