- 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
- $691.83 / $1,174.90 / $2,818.38
| Professional | | $691.83 | $1,174.90 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,737.80 / $6,606.93
| Facility | | $1,148.15 | $1,737.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,584.89 / $2,290.87
| Professional | | $1,513.56 | $1,584.89 | $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 |