- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $2,511.89 / $6,760.83
| Facility | | $616.60 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $831.76 / $1,548.82
| Professional | | $416.87 | $831.76 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,318.26 / $8,317.64
| Facility | | $794.33 | $1,318.26 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,380.38
| Professional | | $933.25 | $1,122.02 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,309.57 / $8,912.51
| Facility | | $4,365.16 | $6,309.57 | $8,912.51 |