- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $5,370.32 / $13,182.57
| Facility | | $776.25 | $5,370.32 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $724.44 / $1,698.24
| Professional | | $478.63 | $724.44 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,951.21 / $7,943.28
| Facility | | $794.33 | $2,951.21 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $1,412.54
| Professional | | $933.25 | $1,258.93 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,570.88 / $8,317.64
| Facility | | $1,819.70 | $4,570.88 | $8,317.64 |