- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,981.07 / $6,760.83
| Facility | | $933.25 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $954.99 / $2,754.23
| Professional | | $575.44 | $954.99 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,698.24 / $15,848.93
| Facility | | $794.33 | $1,698.24 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $1,862.09
| Professional | | $1,230.27 | $1,584.89 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,511.38 / $11,748.98
| Facility | | $5,248.07 | $8,511.38 | $11,748.98 |