- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $6,456.54 / $8,128.31
| Facility | | $758.58 | $6,456.54 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $660.69 / $1,513.56
| Professional | | $416.87 | $660.69 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,258.93 / $8,317.64
| Facility | | $660.69 | $1,258.93 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $1,288.25
| Professional | | $933.25 | $1,071.52 | $1,288.25 |
- 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 |