- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,981.07 / $6,760.83
| Facility | | $1,148.15 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $912.01 / $2,344.23
| Professional | | $524.81 | $912.01 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,778.28 / $8,912.51
| Facility | | $758.58 | $1,778.28 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $1,949.84
| Professional | | $1,000.00 | $1,659.59 | $1,949.84 |
- 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 |