- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $4,365.16 / $7,079.46
| Facility | | $295.12 | $4,365.16 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $562.34 / $1,258.93
| Professional | | $338.84 | $562.34 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $9,332.54 / $21,877.62
| Facility | | $676.08 | $9,332.54 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $912.01 / $1,348.96
| Professional | | $794.33 | $912.01 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $12,022.64 / $21,877.62
| Facility | | $8,511.38 | $12,022.64 | $21,877.62 |