- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,235.94 / $6,760.83
| Facility | | $1,148.15 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $831.76 / $1,513.56
| Professional | | $478.63 | $831.76 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,905.46 / $7,079.46
| Facility | | $954.99 | $1,905.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $1,737.80
| Professional | | $1,071.52 | $1,513.56 | $1,737.80 |
- 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 |