- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $5,370.32 / $7,943.28
| Facility | | $1,479.11 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,905.46 / $4,073.80
| Professional | | $1,148.15 | $1,905.46 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,388.44 / $13,182.57
| Facility | | $1,479.11 | $3,388.44 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,754.23 / $3,548.13
| Professional | | $2,344.23 | $2,754.23 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $10,471.29 / $16,218.10
| Facility | | $6,918.31 | $10,471.29 | $16,218.10 |