- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $8,317.64 / $8,317.64
| Facility | | $2,137.96 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,819.70 / $2,818.38
| Professional | | $512.86 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $16,218.10 / $41,686.94
| Facility | | $9,120.11 | $16,218.10 | $41,686.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $10,471.29 / $16,595.87
| Facility | | $5,370.32 | $10,471.29 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Professional | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,709.64 / $15,135.61
| Facility | | $3,311.31 | $8,709.64 | $15,135.61 |