- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $6,025.60 / $7,943.28
| Facility | | $1,995.26 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $5,495.41
| Professional | | $1,380.38 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,413.10 / $27,542.29
| Facility | | $2,398.83 | $7,413.10 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,235.94 / $4,786.30
| Professional | | $3,019.95 | $3,235.94 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $28,183.83
| Facility | | $8,511.38 | $13,489.63 | $28,183.83 |