- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $3,981.07 / $6,760.83
| Facility | | $309.03 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $416.87 / $758.58
| Professional | | $251.19 | $416.87 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $2,951.21 / $8,709.64
| Facility | | $436.52 | $2,951.21 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $575.44 / $851.14
| Professional | | $562.34 | $575.44 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,309.57 / $8,912.51
| Facility | | $4,265.80 | $6,309.57 | $8,912.51 |