- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $3,981.07 / $6,760.83
| Facility | | $616.60 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $645.65 / $1,905.46
| Professional | | $371.54 | $645.65 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $2,951.21 / $9,332.54
| Facility | | $616.60 | $2,951.21 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $870.96 / $1,148.15
| Professional | | $758.58 | $870.96 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,456.54 / $9,332.54
| Facility | | $4,365.16 | $6,456.54 | $9,332.54 |