- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,981.07 / $6,760.83
| Facility | | $741.31 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $645.65 / $2,187.76
| Professional | | $436.52 | $645.65 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,258.93 / $8,912.51
| Facility | | $741.31 | $1,258.93 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,148.15 / $1,258.93
| Professional | | $1,023.29 | $1,148.15 | $1,258.93 |
- 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 |