- 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
- $741.31 / $1,348.96 / $2,951.21
| Professional | | $741.31 | $1,348.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,905.46 / $7,413.10
| Facility | | $977.24 | $1,905.46 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $3,019.95
| Professional | | $1,548.82 | $1,778.28 | $3,019.95 |
- 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 |