- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,235.94 / $6,760.83
| Facility | | $933.25 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $794.33 / $1,584.89
| Professional | | $501.19 | $794.33 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,187.76 / $8,317.64
| Facility | | $933.25 | $2,187.76 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $1,949.84
| Professional | | $1,202.26 | $1,348.96 | $1,949.84 |
- 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 |