- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,981.07 / $6,760.83
| Facility | | $933.25 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $812.83 / $2,454.71
| Professional | | $512.86 | $812.83 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,548.82 / $8,912.51
| Facility | | $812.83 | $1,548.82 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,318.26 / $1,584.89
| Professional | | $1,148.15 | $1,318.26 | $1,584.89 |
- 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 |