- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $6,606.93 / $8,128.31
| Facility | | $2,187.76 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $5,623.41
| Professional | | $1,318.26 | $2,187.76 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,570.88 / $16,218.10
| Facility | | $2,238.72 | $4,570.88 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $4,570.88
| Professional | | $2,884.03 | $3,019.95 | $4,570.88 |
- 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 |