- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,981.07 / $6,760.83
| Facility | | $1,174.90 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $3,090.30
| Professional | | $758.58 | $1,174.90 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,041.74 / $6,025.60
| Facility | | $1,071.52 | $2,041.74 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,905.46 / $2,290.87
| Professional | | $1,621.81 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $7,413.10
| Facility | | $3,019.95 | $5,370.32 | $7,413.10 |