- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $3,235.94
| Facility | | $2,089.30 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,818.38
| Professional | | $1,023.29 | $1,023.29 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,786.30 / $6,025.60
| Facility | | $3,162.28 | $4,786.30 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,949.84 / $3,388.44
| Facility | | $562.34 | $1,949.84 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,862.09 / $3,715.35
| Facility | | $1,096.48 | $1,862.09 | $3,715.35 |