- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,786.30 / $7,079.46
| Facility | | $1,584.89 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,096.48 / $2,511.89
| Professional | | $645.65 | $1,096.48 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,454.71 / $7,079.46
| Facility | | $1,230.27 | $2,454.71 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $2,398.83
| Professional | | $1,348.96 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,888.44 / $7,762.47
| Facility | | $3,467.37 | $5,888.44 | $7,762.47 |