- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $6,606.93 / $8,128.31
| Facility | | $1,174.90 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,202.26 / $2,754.23
| Professional | | $707.95 | $1,202.26 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,570.88 / $16,218.10
| Facility | | $1,202.26 | $4,570.88 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,659.59 / $2,454.71
| Professional | | $1,548.82 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,715.19 / $15,488.17
| Facility | | $7,413.10 | $10,715.19 | $15,488.17 |