- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,248.07 / $7,943.28
| Facility | | $1,348.96 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $977.24 / $2,398.83
| Professional | | $562.34 | $977.24 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,290.87 / $6,918.31
| Facility | | $1,258.93 | $2,290.87 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $2,089.30
| Professional | | $1,258.93 | $1,819.70 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,128.61 / $7,244.36
| Facility | | $3,019.95 | $5,128.61 | $7,244.36 |