- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,981.07 / $6,760.83
| Facility | | $977.24 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $831.76 / $1,905.46
| Professional | | $489.78 | $831.76 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,513.56 / $8,912.51
| Facility | | $891.25 | $1,513.56 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $1,698.24
| Professional | | $1,122.02 | $1,348.96 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |