- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,467.37 / $6,456.54
| Facility | | $602.56 | $3,467.37 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $933.25 / $1,584.89
| Professional | | $524.81 | $933.25 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,621.81 / $7,079.46
| Facility | | $870.96 | $1,621.81 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $1,949.84
| Professional | | $1,148.15 | $1,548.82 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,309.57 / $8,912.51
| Facility | | $3,801.89 | $6,309.57 | $8,912.51 |