- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,548.13 / $6,760.83
| Facility | | $933.25 | $3,548.13 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $831.76 / $2,187.76
| Professional | | $537.03 | $831.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,513.56 / $7,244.36
| Facility | | $812.83 | $1,513.56 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $2,041.74
| Professional | | $1,202.26 | $1,479.11 | $2,041.74 |
- 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 |