- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,570.40 / $6,760.83
| Facility | | $1,023.29 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $870.96 / $1,862.09
| Professional | | $501.19 | $870.96 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,584.89 / $8,128.31
| Facility | | $831.76 | $1,584.89 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $1,778.28
| Professional | | $1,148.15 | $1,380.38 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $8,912.51
| Facility | | $3,162.28 | $5,495.41 | $8,912.51 |