- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,370.32 / $7,943.28
| Facility | | $1,122.02 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,288.25 / $2,884.03
| Professional | | $758.58 | $1,288.25 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,905.46 / $7,079.46
| Facility | | $1,148.15 | $1,905.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $2,290.87
| Professional | | $1,513.56 | $1,737.80 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |