- 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
- $549.54 / $891.25 / $2,290.87
| Professional | | $549.54 | $891.25 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,621.81 / $5,128.61
| Facility | | $1,047.13 | $1,621.81 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $1,778.28
| Professional | | $1,230.27 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $6,309.57
| Facility | | $2,570.40 | $4,677.35 | $6,309.57 |