- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $4,570.88 / $7,079.46
| Facility | | $426.58 | $4,570.88 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $758.58 / $2,238.72
| Professional | | $446.68 | $758.58 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $4,677.35 / $15,848.93
| Facility | | $724.44 | $4,677.35 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,023.29 / $1,445.44
| Professional | | $954.99 | $1,023.29 | $1,445.44 |
- 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 |