- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,370.32 / $7,943.28
| Facility | | $1,380.38 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,862.09 / $3,801.89
| Professional | | $1,148.15 | $1,862.09 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,162.28 / $8,511.38
| Facility | | $1,513.56 | $3,162.28 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,570.40 / $3,630.78
| Professional | | $2,398.83 | $2,570.40 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,309.57 / $10,232.93
| Facility | | $3,388.44 | $6,309.57 | $10,232.93 |