- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,162.28 / $6,760.83
| Facility | | $812.83 | $3,162.28 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $707.95 / $1,584.89
| Professional | | $436.52 | $707.95 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,258.93 / $8,128.31
| Facility | | $630.96 | $1,258.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $1,513.56
| Professional | | $851.14 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $8,912.51
| Facility | | $3,162.28 | $5,495.41 | $8,912.51 |