- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,981.07 / $7,943.28
| Facility | | $645.65 | $3,981.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $616.60 / $2,137.96
| Professional | | $380.19 | $616.60 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,122.02 / $17,782.79
| Facility | | $645.65 | $1,122.02 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $954.99 / $1,148.15
| Professional | | $831.76 | $954.99 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,549.93 / $19,498.45
| Facility | | $5,495.41 | $9,549.93 | $19,498.45 |