- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $5,370.32 / $7,943.28
| Facility | | $707.95 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $707.95 / $1,862.09
| Professional | | $446.68 | $707.95 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,258.93 / $6,606.93
| Facility | | $707.95 | $1,258.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,122.02 / $1,819.70
| Professional | | $912.01 | $1,122.02 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |