- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $6,606.93 / $8,128.31
| Facility | | $1,698.24 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,041.74 / $3,467.37
| Professional | | $1,148.15 | $2,041.74 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $9,549.93 / $26,915.35
| Facility | | $1,737.80 | $9,549.93 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,754.23 / $4,365.16
| Professional | | $2,511.89 | $2,754.23 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $15,135.61 / $28,183.83
| Facility | | $9,549.93 | $15,135.61 | $28,183.83 |