- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $3,801.89 / $6,760.83
| Facility | | $660.69 | $3,801.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $676.08 / $1,288.25
| Professional | | $371.54 | $676.08 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,122.02 / $7,244.36
| Facility | | $588.84 | $1,122.02 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,122.02 / $1,513.56
| Professional | | $912.01 | $1,122.02 | $1,513.56 |
- 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 |