- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $3,090.30 / $6,760.83
| Facility | | $575.44 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $691.83 / $1,479.11
| Professional | | $309.03 | $691.83 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,023.29 / $6,918.31
| Facility | | $575.44 | $1,023.29 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $954.99 / $1,479.11
| Professional | | $831.76 | $954.99 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,309.57 / $8,912.51
| Facility | | $4,168.69 | $6,309.57 | $8,912.51 |