- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $4,786.30 / $8,511.38
| Facility | | $575.44 | $4,786.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $616.60 / $1,737.80
| Professional | | $354.81 | $616.60 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,951.21 / $9,332.54
| Facility | | $660.69 | $2,951.21 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $831.76 / $1,202.26
| Professional | | $776.25 | $831.76 | $1,202.26 |
- 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 |