- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,128.61 / $7,943.28
| Facility | | $1,318.26 | $5,128.61 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $3,235.94
| Professional | | $1,258.93 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,238.72 / $6,606.93
| Facility | | $1,445.44 | $2,238.72 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $3,890.45
| Professional | | $2,187.76 | $2,511.89 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,951.21 / $7,413.10
| Facility | | $1,348.96 | $2,951.21 | $7,413.10 |