- 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 / $794.33 / $1,698.24
| Professional | | $489.78 | $794.33 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,513.56 / $7,079.46
| Facility | | $645.65 | $1,513.56 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $1,584.89
| Professional | | $831.76 | $1,412.54 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $7,762.47
| Facility | | $3,162.28 | $5,495.41 | $7,762.47 |