- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,090.30 / $6,760.83
| Facility | | $977.24 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $954.99 / $2,238.72
| Professional | | $575.44 | $954.99 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,659.59 / $7,244.36
| Facility | | $870.96 | $1,659.59 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $2,089.30
| Professional | | $1,380.38 | $1,659.59 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $8,912.51
| Facility | | $4,365.16 | $6,606.93 | $8,912.51 |