- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $3,981.07 / $6,760.83
| Facility | | $758.58 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $660.69 / $2,137.96
| Professional | | $426.58 | $660.69 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,258.93 / $8,317.64
| Facility | | $660.69 | $1,258.93 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,096.48 / $1,288.25
| Professional | | $954.99 | $1,096.48 | $1,288.25 |
- 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 |