- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,570.40 / $6,760.83
| Facility | | $831.76 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $691.83 / $1,513.56
| Professional | | $467.74 | $691.83 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,288.25 / $7,413.10
| Facility | | $645.65 | $1,288.25 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $1,380.38
| Professional | | $758.58 | $1,096.48 | $1,380.38 |
- 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 |