- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $7,079.46
| Facility | | $1,023.29 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $912.01 / $3,090.30
| Professional | | $588.84 | $912.01 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,737.80 / $8,912.51
| Facility | | $1,023.29 | $1,737.80 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,479.11 / $1,778.28
| Professional | | $1,288.25 | $1,479.11 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- 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 |