- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,981.07 / $6,760.83
| Facility | | $1,023.29 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $2,754.23
| Professional | | $616.60 | $891.25 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,659.59 / $17,782.79
| Facility | | $1,023.29 | $1,659.59 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $1,737.80
| Professional | | $1,412.54 | $1,584.89 | $1,737.80 |
- 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 |