- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $5,370.32 / $7,943.28
| Facility | | $1,258.93 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,479.11 / $3,630.78
| Professional | | $851.14 | $1,479.11 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,511.89 / $7,762.47
| Facility | | $1,513.56 | $2,511.89 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,995.26 / $2,754.23
| Professional | | $1,819.70 | $1,995.26 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,606.93 / $10,232.93
| Facility | | $3,981.07 | $6,606.93 | $10,232.93 |