- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,248.07 / $7,943.28
| Facility | | $1,737.80 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $3,981.07
| Professional | | $1,023.29 | $1,513.56 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,884.03 / $14,454.40
| Facility | | $1,513.56 | $2,884.03 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $2,884.03
| Professional | | $2,187.76 | $2,511.89 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,964.78 / $15,848.93
| Facility | | $7,413.10 | $10,964.78 | $15,848.93 |