- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,570.40 / $6,760.83
| Facility | | $1,513.56 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,348.96 / $2,691.53
| Professional | | $891.25 | $1,348.96 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,137.96 / $5,495.41
| Facility | | $1,071.52 | $2,137.96 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,187.76 / $2,570.40
| Professional | | $1,905.46 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $6,309.57
| Facility | | $2,570.40 | $4,677.35 | $6,309.57 |