- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,090.30 / $6,760.83
| Facility | | $398.11 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $588.84 / $1,023.29
| Professional | | $239.88 | $588.84 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $933.25 / $7,244.36
| Facility | | $398.11 | $933.25 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $954.99 / $1,230.27
| Professional | | $562.34 | $954.99 | $1,230.27 |
- 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 |