- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,981.07 / $6,760.83
| Facility | | $1,174.90 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,023.29 / $3,019.95
| Professional | | $588.84 | $1,023.29 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,862.09 / $7,079.46
| Facility | | $1,122.02 | $1,862.09 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $1,949.84
| Professional | | $1,288.25 | $1,698.24 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $7,762.47
| Facility | | $3,162.28 | $5,495.41 | $7,762.47 |