- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,981.07 / $6,760.83
| Facility | | $1,023.29 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $912.01 / $2,951.21
| Professional | | $616.60 | $912.01 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,737.80 / $8,912.51
| Facility | | $812.83 | $1,737.80 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $1,737.80
| Professional | | $1,258.93 | $1,548.82 | $1,737.80 |
- 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 |