- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,606.93 / $8,128.31
| Facility | | $2,570.40 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,570.40 / $7,079.46
| Professional | | $1,548.82 | $2,570.40 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $16,218.10
| Facility | | $2,570.40 | $4,570.88 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,548.13 / $5,248.07
| Professional | | $3,388.44 | $3,548.13 | $5,248.07 |
- 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 |