- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,370.32 / $7,943.28
| Facility | | $1,445.44 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,479.11 / $2,951.21
| Professional | | $812.83 | $1,479.11 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,584.89 / $3,388.44
| Facility | | $870.96 | $1,584.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $2,398.83
| Professional | | $1,513.56 | $1,995.26 | $2,398.83 |
- 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 |