- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $5,248.07 / $7,943.28
| Facility | | $1,778.28 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,778.28 / $4,897.79
| Professional | | $1,071.52 | $1,778.28 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,570.88 / $16,218.10
| Facility | | $1,905.46 | $4,570.88 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,454.71 / $3,548.13
| Professional | | $2,344.23 | $2,454.71 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,715.19 / $15,488.17
| Facility | | $7,413.10 | $10,715.19 | $15,488.17 |