- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,786.30 / $7,079.46
| Facility | | $1,096.48 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $794.33 / $1,548.82
| Professional | | $457.09 | $794.33 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,949.84 / $7,079.46
| Facility | | $954.99 | $1,949.84 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $1,698.24
| Professional | | $1,023.29 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,754.40 / $7,585.78
| Facility | | $3,311.31 | $5,754.40 | $7,585.78 |