- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $2,511.89 / $6,760.83
| Facility | | $316.23 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $1,412.54 / $2,511.89
| Professional | | $199.53 | $1,412.54 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $2,454.71 / $6,165.95
| Facility | | $512.86 | $2,454.71 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $2,137.96 / $2,818.38
| Professional | | $467.74 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $7,413.10
| Facility | | $3,019.95 | $5,370.32 | $7,413.10 |