- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $5,370.32 / $7,943.28
| Facility | | $1,096.48 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,071.52 / $2,290.87
| Professional | | $446.68 | $1,071.52 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,951.21 / $8,317.64
| Facility | | $1,202.26 | $2,951.21 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $2,344.23
| Professional | | $1,548.82 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,570.88 / $8,317.64
| Facility | | $1,819.70 | $4,570.88 | $8,317.64 |