- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $5,248.07 / $7,943.28
| Facility | | $676.08 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $912.01 / $2,089.30
| Professional | | $549.54 | $912.01 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,548.82 / $7,413.10
| Facility | | $831.76 | $1,548.82 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,230.27 / $1,621.81
| Professional | | $1,071.52 | $1,230.27 | $1,621.81 |
- 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 |