- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,981.07 / $6,760.83
| Facility | | $1,202.26 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $870.96 / $2,187.76
| Professional | | $501.19 | $870.96 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,951.21 / $10,232.93
| Facility | | $1,096.48 | $2,951.21 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $1,819.70
| Professional | | $1,412.54 | $1,659.59 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $10,964.78
| Facility | | $4,365.16 | $6,606.93 | $10,964.78 |