- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $9,772.37 / $16,595.87
| Facility | | $1,513.56 | $9,772.37 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $10,232.93
| Professional | | $676.08 | $676.08 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $8,709.64 / $10,715.19
| Facility | | $3,090.30 | $8,709.64 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $8,511.38 / $18,197.01
| Facility | | $3,715.35 | $8,511.38 | $18,197.01 |