- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,981.07 / $7,762.47
| Facility | | $1,380.38 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $22,908.68 / $22,908.68
| Professional | | $6,606.93 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $19,498.45 / $32,359.37
| Facility | | $12,589.25 | $19,498.45 | $32,359.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $6,918.31 / $15,135.61
| Facility | | $1,862.09 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $7,943.28 / $15,135.61
| Facility | | $1,949.84 | $7,943.28 | $15,135.61 |