- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $5,370.32 / $7,943.28
| Facility | | $537.03 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $524.81 / $1,230.27
| Professional | | $331.13 | $524.81 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $954.99 / $7,079.46
| Facility | | $616.60 | $954.99 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $831.76 / $1,288.25
| Professional | | $616.60 | $831.76 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |