- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $4,570.88 / $7,079.46
| Facility | | $501.19 | $4,570.88 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $3,162.28 / $7,585.78
| Professional | | $338.84 | $3,162.28 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $7,079.46 / $14,454.40
| Facility | | $741.31 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $5,754.40 / $8,709.64
| Professional | | $645.65 | $5,754.40 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $11,481.54 / $15,848.93
| Facility | | $7,943.28 | $11,481.54 | $15,848.93 |