- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $7,079.46
| Facility | | $1,023.29 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $870.96 / $1,737.80
| Professional | | $537.03 | $870.96 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,659.59 / $8,317.64
| Facility | | $758.58 | $1,659.59 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $1,737.80
| Professional | | $1,258.93 | $1,479.11 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $8,912.51
| Facility | | $4,365.16 | $6,606.93 | $8,912.51 |