- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $4,786.30 / $7,079.46
| Facility | | $549.54 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $588.84 / $1,202.26
| Professional | | $331.13 | $588.84 | $1,202.26 |
- 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 |