- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $3,981.07 / $6,760.83
| Facility | | $912.01 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $724.44 / $1,513.56
| Professional | | $426.58 | $724.44 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,949.84 / $7,079.46
| Facility | | $794.33 | $1,949.84 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,380.38
| Professional | | $831.76 | $1,202.26 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,754.40 / $7,585.78
| Facility | | $3,311.31 | $5,754.40 | $7,585.78 |