- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,677.35 / $8,317.64
| Facility | | $2,089.30 | $4,677.35 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $18,197.01 / $18,197.01
| Professional | | $2,238.72 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,981.07 / $5,888.44
| Facility | | $1,230.27 | $3,981.07 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $3,388.44 / $18,620.87
| Professional | | $691.83 | $3,388.44 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $13,803.84 / $25,703.96
| Facility | | $4,466.84 | $13,803.84 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $10,471.29 / $17,782.79
| Facility | | $4,570.88 | $10,471.29 | $17,782.79 |