- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $5,248.07 / $7,943.28
| Facility | | $691.83 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $912.01 / $2,570.40
| Professional | | $549.54 | $912.01 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,951.21 / $8,709.64
| Facility | | $977.24 | $2,951.21 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $1,819.70
| Professional | | $1,202.26 | $1,258.93 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,309.57 / $8,912.51
| Facility | | $4,265.80 | $6,309.57 | $8,912.51 |