- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,981.07 / $6,760.83
| Facility | | $645.65 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $660.69 / $1,584.89
| Professional | | $389.05 | $660.69 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $3,162.28 / $9,549.93
| Facility | | $691.83 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $1,202.26
| Professional | | $812.83 | $912.01 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,762.47 / $10,715.19
| Facility | | $4,786.30 | $7,762.47 | $10,715.19 |