- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,834.13 / $5,463.36 / $13,841.56
| Facility | | $2,834.13 | $5,463.36 | $13,841.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.42 / $1,898.00 / $2,046.84
| Professional | | $1,023.42 | $1,898.00 | $2,046.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,252.94 / $3,266.13 / $5,731.84
| Facility | | $2,252.94 | $3,266.13 | $5,731.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.09 / $3,044.00 / $7,934.00
| Facility | | $1,167.09 | $3,044.00 | $7,934.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $3,726.00 / $7,934.00
| Facility | | $3,044.00 | $3,726.00 | $7,934.00 |