- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $3,090.30 / $6,456.54
| Facility | | $676.08 | $3,090.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $588.84 / $1,258.93
| Professional | | $363.08 | $588.84 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,122.02 / $8,317.64
| Facility | | $588.84 | $1,122.02 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $954.99 / $1,174.90
| Professional | | $812.83 | $954.99 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $8,912.51
| Facility | | $4,365.16 | $6,606.93 | $8,912.51 |