- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,981.07 / $6,760.83
| Facility | | $812.83 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $724.44 / $1,659.59
| Professional | | $467.74 | $724.44 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,380.38 / $8,912.51
| Facility | | $812.83 | $1,380.38 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,174.90 / $1,412.54
| Professional | | $1,023.29 | $1,174.90 | $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 |