- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,786.30 / $7,079.46
| Facility | | $1,202.26 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $870.96 / $2,570.40
| Professional | | $501.19 | $870.96 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,995.26 / $7,079.46
| Facility | | $1,122.02 | $1,995.26 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $1,819.70
| Professional | | $1,148.15 | $1,621.81 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,888.44 / $7,762.47
| Facility | | $3,467.37 | $5,888.44 | $7,762.47 |