- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,981.07 / $6,760.83
| Facility | | $851.14 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $776.25 / $1,862.09
| Professional | | $478.63 | $776.25 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $17,782.79
| Facility | | $851.14 | $1,445.44 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,230.27 / $1,479.11
| Professional | | $1,071.52 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $19,498.45
| Facility | | $7,413.10 | $11,481.54 | $19,498.45 |