- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $5,248.07 / $7,943.28
| Facility | | $1,174.90 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,621.81 / $2,818.38
| Professional | | $954.99 | $1,621.81 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,691.53 / $6,606.93
| Facility | | $1,288.25 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $3,162.28
| Professional | | $2,089.30 | $2,187.76 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,248.07 / $7,585.78
| Facility | | $3,019.95 | $5,248.07 | $7,585.78 |