- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,786.30 / $7,943.28
| Facility | | $1,047.13 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $2,511.89
| Professional | | $602.56 | $933.25 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,737.80 / $8,912.51
| Facility | | $1,047.13 | $1,737.80 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,479.11 / $1,819.70
| Professional | | $1,288.25 | $1,479.11 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |