- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,456.54 / $8,128.31
| Facility | | $1,230.27 | $6,456.54 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,398.83 / $5,623.41
| Professional | | $1,445.44 | $2,398.83 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,570.88 / $16,218.10
| Facility | | $2,398.83 | $4,570.88 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,311.31 / $5,011.87
| Professional | | $3,235.94 | $3,311.31 | $5,011.87 |
- 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 |