- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,370.32 / $7,943.28
| Facility | | $1,148.15 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,096.48 / $2,884.03
| Professional | | $707.95 | $1,096.48 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $7,413.10
| Facility | | $1,348.96 | $2,041.74 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $3,715.35
| Professional | | $1,513.56 | $1,819.70 | $3,715.35 |
- 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 |