- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,370.32 / $7,943.28
| Facility | | $1,202.26 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $2,818.38
| Professional | | $794.33 | $1,288.25 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,365.16 / $15,848.93
| Facility | | $1,202.26 | $4,365.16 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,778.28 / $2,630.27
| Professional | | $1,737.80 | $1,778.28 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $15,488.17
| Facility | | $4,365.16 | $7,079.46 | $15,488.17 |