- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,584.89 / $5,370.32
| Facility | | $691.83 | $1,584.89 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,548.82 / $3,981.07
| Professional | | $354.81 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,025.60 / $8,317.64
| Facility | | $5,128.61 | $6,025.60 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $7,079.46
| Facility | | $1,479.11 | $4,365.16 | $7,079.46 |