- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $3,235.94 / $6,760.83
| Facility | | $724.44 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $630.96 / $1,548.82
| Professional | | $389.05 | $630.96 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,174.90 / $8,317.64
| Facility | | $616.60 | $1,174.90 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $1,230.27
| Professional | | $870.96 | $1,023.29 | $1,230.27 |
- 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 |