- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $5,248.07 / $7,943.28
| Facility | | $724.44 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $630.96 / $1,380.38
| Professional | | $407.38 | $630.96 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,202.26 / $8,317.64
| Facility | | $616.60 | $1,202.26 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $1,230.27
| Professional | | $891.25 | $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 |