- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $3,801.89 / $6,760.83
| Facility | | $436.52 | $3,801.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $707.95 / $2,290.87
| Professional | | $478.63 | $707.95 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,318.26 / $8,912.51
| Facility | | $794.33 | $1,318.26 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $1,348.96
| Professional | | $1,047.13 | $1,202.26 | $1,348.96 |
- 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 |