- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $6,025.60 / $7,943.28
| Facility | | $1,862.09 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $4,677.35
| Professional | | $1,258.93 | $2,238.72 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $7,413.10 / $27,542.29
| Facility | | $2,238.72 | $7,413.10 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,019.95 / $4,365.16
| Professional | | $2,754.23 | $3,019.95 | $4,365.16 |
- 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 |