- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,897.79 / $11,220.18
| Facility | | $977.24 | $4,897.79 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $154.88 / $3,890.45
| Professional | | $81.28 | $154.88 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |