- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,089.30 / $8,128.31
| Facility | | $776.25 | $2,089.30 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,122.02
| Professional | | $912.01 | $912.01 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $660.69 / $870.96
| Facility | | $537.03 | $660.69 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $10,471.29
| Facility | | $2,454.71 | $7,244.36 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $28,840.32
| Facility | | $7,943.28 | $7,943.28 | $28,840.32 |