- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $3,090.30 / $6,760.83
| Facility | | $263.03 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $645.65 / $1,288.25
| Professional | | $177.83 | $645.65 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $977.24 / $5,623.41
| Facility | | $398.11 | $977.24 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $831.76 / $1,122.02
| Professional | | $338.84 | $831.76 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,011.87 / $6,918.31
| Facility | | $2,754.23 | $5,011.87 | $6,918.31 |