- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $11,748.98
| Facility | | $4,466.84 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $5,888.44 / $12,302.69
| Professional | | $309.03 | $5,888.44 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $3,548.13
| Facility | | $1,380.38 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,548.13 / $7,762.47
| Facility | | $1,698.24 | $3,548.13 | $7,762.47 |