- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $4,786.30 / $7,943.28
| Facility | | $467.74 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $562.34 / $1,698.24
| Professional | | $316.23 | $562.34 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $4,073.80 / $13,803.84
| Facility | | $588.84 | $4,073.80 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $758.58 / $1,148.15
| Professional | | $691.83 | $758.58 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $14,125.38
| Facility | | $4,365.16 | $7,079.46 | $14,125.38 |