- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,370.32 / $7,943.28
| Facility | | $1,659.59 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,698.24 / $3,090.30
| Professional | | $912.01 | $1,698.24 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,778.28 / $3,388.44
| Facility | | $977.24 | $1,778.28 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $2,691.53
| Professional | | $1,698.24 | $2,238.72 | $2,691.53 |
- 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 |