- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,090.30 / $6,456.54
| Facility | | $1,122.02 | $3,090.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $912.01 / $2,137.96
| Professional | | $549.54 | $912.01 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,737.80 / $8,128.31
| Facility | | $831.76 | $1,737.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $1,905.46
| Professional | | $1,230.27 | $1,513.56 | $1,905.46 |
- 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 |