- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $3,090.30 / $6,760.83
| Facility | | $549.54 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $616.60 / $1,949.84
| Professional | | $323.59 | $616.60 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,122.02 / $7,244.36
| Facility | | $549.54 | $1,122.02 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $977.24 / $1,479.11
| Professional | | $851.14 | $977.24 | $1,479.11 |
- 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 |