- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,981.07 / $6,760.83
| Facility | | $630.96 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $562.34 / $1,412.54
| Professional | | $380.19 | $562.34 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,071.52 / $8,317.64
| Facility | | $616.60 | $1,071.52 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $954.99 / $1,071.52
| Professional | | $851.14 | $954.99 | $1,071.52 |
- 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 |