- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $2,454.71
| Facility | | $794.33 | $1,071.52 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $8,128.31 / $8,128.31
| Professional | | $457.09 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $562.34 / $2,818.38
| Facility | | $512.86 | $562.34 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,862.09 / $7,079.46
| Facility | | $891.25 | $1,862.09 | $7,079.46 |