- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $3,981.07 / $6,760.83
| Facility | | $870.96 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $933.25 / $2,137.96
| Professional | | $524.81 | $933.25 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,162.28 / $9,549.93
| Facility | | $891.25 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,230.27 / $1,698.24
| Professional | | $1,122.02 | $1,230.27 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,762.47 / $10,715.19
| Facility | | $4,786.30 | $7,762.47 | $10,715.19 |