- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,786.30 / $7,079.46
| Facility | | $977.24 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $870.96 / $2,754.23
| Professional | | $562.34 | $870.96 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,659.59 / $8,912.51
| Facility | | $977.24 | $1,659.59 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $1,659.59
| Professional | | $1,230.27 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |