- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,890.45 / $7,943.28
| Facility | | $1,778.28 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,548.13 / $4,897.79
| Professional | | $2,511.89 | $3,548.13 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $691.83 / $776.25
| Professional | | $602.56 | $691.83 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,235.94 / $11,220.18
| Facility | | $1,174.90 | $3,235.94 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,818.38 / $10,471.29
| Facility | | $1,380.38 | $2,818.38 | $10,471.29 |