- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $6,025.60 / $7,943.28
| Facility | | $1,584.89 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,659.59 / $3,388.44
| Professional | | $891.25 | $1,659.59 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,737.80 / $3,388.44
| Facility | | $977.24 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $2,630.27
| Professional | | $1,659.59 | $2,187.76 | $2,630.27 |
- 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 |