- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $6,025.60 / $7,943.28
| Facility | | $1,479.11 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $4,073.80
| Professional | | $933.25 | $1,479.11 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $8,128.31 / $14,454.40
| Facility | | $1,862.09 | $8,128.31 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,398.83 / $3,630.78
| Professional | | $2,187.76 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,481.54 / $15,135.61
| Facility | | $7,244.36 | $11,481.54 | $15,135.61 |