- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,981.07 / $6,760.83
| Facility | | $1,288.25 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,230.27 / $3,801.89
| Professional | | $794.33 | $1,230.27 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,344.23 / $7,585.78
| Facility | | $1,202.26 | $2,344.23 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $2,630.27
| Professional | | $1,737.80 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,309.57 / $8,912.51
| Facility | | $3,801.89 | $6,309.57 | $8,912.51 |