- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,370.32 / $7,943.28
| Facility | | $1,288.25 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,318.26 / $2,344.23
| Professional | | $724.44 | $1,318.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,412.54 / $3,388.44
| Facility | | $776.25 | $1,412.54 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $2,089.30
| Professional | | $1,318.26 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |