- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $4,365.16
| Facility | | $933.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,819.70 / $2,089.30
| Professional | | $549.54 | $1,819.70 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,754.40 / $11,481.54
| Facility | | $2,511.89 | $5,754.40 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,630.27 / $6,606.93
| Facility | | $831.76 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $3,801.89
| Professional | | $1,698.24 | $2,344.23 | $3,801.89 |