- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $5,248.07 / $7,943.28
| Facility | | $281.84 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $288.40 / $2,570.40
| Professional | | $173.78 | $288.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $1,548.82 / $5,248.07
| Facility | | $213.80 | $1,548.82 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $407.38 / $467.74
| Professional | | $302.00 | $407.38 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $6,309.57
| Facility | | $2,570.40 | $4,677.35 | $6,309.57 |