- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $5,248.07 / $7,943.28
| Facility | | $812.83 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,174.90 / $2,398.83
| Professional | | $676.08 | $1,174.90 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,677.35 / $15,848.93
| Facility | | $977.24 | $4,677.35 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $2,344.23
| Professional | | $1,513.56 | $1,548.82 | $2,344.23 |
- 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 |