- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $3,981.07 / $6,760.83
| Facility | | $954.99 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $812.83 / $1,862.09
| Professional | | $501.19 | $812.83 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $5,128.61
| Facility | | $933.25 | $1,479.11 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $1,659.59
| Professional | | $1,122.02 | $1,348.96 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $6,309.57
| Facility | | $2,570.40 | $4,677.35 | $6,309.57 |