- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $4,265.80 / $7,413.10
| Facility | | $501.19 | $4,265.80 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $724.44 / $1,698.24
| Professional | | $489.78 | $724.44 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,412.54 / $17,782.79
| Facility | | $794.33 | $1,412.54 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $1,513.56
| Professional | | $912.01 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |