- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $4,466.84 / $7,079.46
| Facility | | $602.56 | $4,466.84 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $724.44 / $2,137.96
| Professional | | $407.38 | $724.44 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $4,073.80 / $13,803.84
| Facility | | $691.83 | $4,073.80 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $977.24 / $1,380.38
| Professional | | $891.25 | $977.24 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $14,125.38
| Facility | | $4,365.16 | $7,079.46 | $14,125.38 |