- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,981.07 / $6,760.83
| Facility | | $831.76 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $2,187.76
| Professional | | $512.86 | $758.58 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $8,912.51
| Facility | | $831.76 | $1,412.54 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $1,412.54
| Professional | | $1,174.90 | $1,318.26 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |