- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,235.94 / $6,760.83
| Facility | | $831.76 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $831.76 / $2,187.76
| Professional | | $537.03 | $831.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,412.54 / $6,025.60
| Facility | | $741.31 | $1,412.54 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $1,548.82
| Professional | | $1,122.02 | $1,348.96 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $7,413.10
| Facility | | $3,019.95 | $5,370.32 | $7,413.10 |