- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $2,570.40 / $6,760.83
| Facility | | $851.14 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $1,949.84
| Professional | | $501.19 | $758.58 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,412.54 / $8,317.64
| Facility | | $707.95 | $1,412.54 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,202.26 / $1,445.44
| Professional | | $1,023.29 | $1,202.26 | $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 |