- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,365.16 / $7,413.10
| Facility | | $1,819.70 | $4,365.16 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $2,344.23 / $6,918.31
| Professional | | $251.19 | $2,344.23 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,388.44 / $7,585.78
| Facility | | $794.33 | $3,388.44 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $2,511.89
| Facility | | $501.19 | $501.19 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $1,479.11 / $2,511.89
| Facility | | $177.83 | $1,479.11 | $2,511.89 |