- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $5,370.32 / $7,943.28
| Facility | | $616.60 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $645.65 / $1,412.54
| Professional | | $346.74 | $645.65 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $707.95 / $2,137.96
| Facility | | $380.19 | $707.95 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $851.14 / $1,023.29
| Professional | | $707.95 | $851.14 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |