- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,570.88 / $7,079.46
| Facility | | $1,778.28 | $4,570.88 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,737.80 / $4,466.84
| Professional | | $1,071.52 | $1,737.80 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,019.95 / $15,135.61
| Facility | | $1,548.82 | $3,019.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $3,715.35
| Professional | | $2,454.71 | $3,019.95 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,413.10 / $19,498.45
| Facility | | $4,365.16 | $7,413.10 | $19,498.45 |