- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $4,786.30 / $7,079.46
| Facility | | $691.83 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $616.60 / $1,778.28
| Professional | | $398.11 | $616.60 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,148.15 / $8,912.51
| Facility | | $660.69 | $1,148.15 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $1,174.90
| Professional | | $891.25 | $1,047.13 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |