- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $2,511.89 / $6,760.83
| Facility | | $912.01 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $851.14 / $1,737.80
| Professional | | $537.03 | $851.14 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,412.54 / $7,244.36
| Facility | | $724.44 | $1,412.54 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,445.44 / $1,698.24
| Professional | | $1,318.26 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $8,912.51
| Facility | | $3,162.28 | $5,495.41 | $8,912.51 |