- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $5,370.32 / $7,943.28
| Facility | | $776.25 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,513.56 / $3,467.37
| Professional | | $812.83 | $1,513.56 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,949.84 / $7,079.46
| Facility | | $1,122.02 | $1,949.84 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,905.46 / $2,818.38
| Professional | | $1,862.09 | $1,905.46 | $2,818.38 |
- 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 |