- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,128.61 / $7,943.28
| Facility | | $1,737.80 | $5,128.61 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,698.24 / $4,466.84
| Professional | | $1,023.29 | $1,698.24 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,570.88 / $16,218.10
| Facility | | $1,698.24 | $4,570.88 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $3,467.37
| Professional | | $2,290.87 | $2,398.83 | $3,467.37 |
- 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 |