- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $6,606.93 / $8,128.31
| Facility | | $1,548.82 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,584.89 / $3,715.35
| Professional | | $933.25 | $1,584.89 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,365.16 / $16,218.10
| Facility | | $1,584.89 | $4,365.16 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,187.76 / $3,311.31
| Professional | | $2,041.74 | $2,187.76 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $15,488.17
| Facility | | $4,365.16 | $7,079.46 | $15,488.17 |