- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $3,981.07 / $6,760.83
| Facility | | $537.03 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $467.74 / $1,047.13
| Professional | | $331.13 | $467.74 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $912.01 / $8,317.64
| Facility | | $537.03 | $912.01 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $870.96 / $912.01
| Professional | | $776.25 | $870.96 | $912.01 |
- 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 |