- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,090.30 / $6,760.83
| Facility | | $794.33 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $758.58 / $1,698.24
| Professional | | $467.74 | $758.58 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,258.93 / $3,548.13
| Facility | | $645.65 | $1,258.93 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,258.93 / $1,513.56
| Professional | | $1,122.02 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,137.96 / $4,365.16
| Facility | | $1,202.26 | $2,137.96 | $4,365.16 |