- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $3,981.07 / $6,760.83
| Facility | | $954.99 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $891.25 / $2,754.23
| Professional | | $588.84 | $891.25 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,905.46 / $7,413.10
| Facility | | $891.25 | $1,905.46 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $1,905.46
| Professional | | $1,258.93 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $7,762.47
| Facility | | $3,162.28 | $5,370.32 | $7,762.47 |