- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $5,248.07 / $7,943.28
| Facility | | $933.25 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $758.58 / $2,398.83
| Professional | | $478.63 | $758.58 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,479.11 / $9,772.37
| Facility | | $660.69 | $1,479.11 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,318.26 / $1,584.89
| Professional | | $1,023.29 | $1,318.26 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,511.38 / $11,748.98
| Facility | | $5,128.61 | $8,511.38 | $11,748.98 |