- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,467.37 / $6,456.54
| Facility | | $933.25 | $3,467.37 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $575.44 / $1,380.38
| Professional | | $380.19 | $575.44 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,096.48 / $7,079.46
| Facility | | $489.78 | $1,096.48 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $933.25 / $1,096.48
| Professional | | $758.58 | $933.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,309.57 / $8,912.51
| Facility | | $4,168.69 | $6,309.57 | $8,912.51 |