- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $5,248.07 / $7,943.28
| Facility | | $1,096.48 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,479.11 / $2,630.27
| Professional | | $831.76 | $1,479.11 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,995.26 / $6,606.93
| Facility | | $1,174.90 | $1,995.26 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,041.74 / $3,019.95
| Professional | | $1,995.26 | $2,041.74 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,897.79 / $7,585.78
| Facility | | $1,445.44 | $4,897.79 | $7,585.78 |