- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,981.07 / $6,760.83
| Facility | | $1,047.13 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,023.29 / $3,162.28
| Professional | | $660.69 | $1,023.29 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,949.84 / $7,585.78
| Facility | | $933.25 | $1,949.84 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,187.76
| Professional | | $1,479.11 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,309.57 / $8,912.51
| Facility | | $3,801.89 | $6,309.57 | $8,912.51 |