- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,090.30 / $6,760.83
| Facility | | $645.65 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $676.08 / $1,318.26
| Professional | | $389.05 | $676.08 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,951.21 / $9,332.54
| Facility | | $645.65 | $2,951.21 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $1,230.27
| Professional | | $812.83 | $912.01 | $1,230.27 |
- 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 |