- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $5,248.07 / $7,943.28
| Facility | | $954.99 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,318.26 / $2,511.89
| Professional | | $741.31 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,187.76 / $7,413.10
| Facility | | $1,023.29 | $2,187.76 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,778.28 / $2,570.40
| Professional | | $1,698.24 | $1,778.28 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,309.57 / $10,232.93
| Facility | | $3,388.44 | $6,309.57 | $10,232.93 |