- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $5,370.32 / $7,943.28
| Facility | | $1,047.13 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,047.13 / $1,949.84
| Professional | | $645.65 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,862.09 / $7,244.36
| Facility | | $1,047.13 | $1,862.09 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,698.24 / $2,238.72
| Professional | | $1,479.11 | $1,698.24 | $2,238.72 |
- 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 |