- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,786.30 / $7,079.46
| Facility | | $1,230.27 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $891.25 / $2,041.74
| Professional | | $512.86 | $891.25 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,137.96 / $7,079.46
| Facility | | $1,148.15 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $1,862.09
| Professional | | $1,148.15 | $1,659.59 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,754.40 / $7,585.78
| Facility | | $3,311.31 | $5,754.40 | $7,585.78 |