- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,981.07 / $6,760.83
| Facility | | $831.76 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $2,398.83
| Professional | | $501.19 | $758.58 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $8,317.64
| Facility | | $831.76 | $1,412.54 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $1,445.44
| Professional | | $1,174.90 | $1,318.26 | $1,445.44 |
- 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 |