- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $6,606.93 / $8,128.31
| Facility | | $977.24 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,862.09 / $4,365.16
| Professional | | $1,047.13 | $1,862.09 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,398.83 / $7,079.46
| Facility | | $1,412.54 | $2,398.83 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $3,467.37
| Professional | | $2,290.87 | $2,398.83 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |