- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $4,265.80 / $6,760.83
| Facility | | $457.09 | $4,265.80 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $602.56 / $1,230.27
| Professional | | $371.54 | $602.56 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $3,548.13 / $12,589.25
| Facility | | $549.54 | $3,548.13 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $831.76 / $1,148.15
| Professional | | $758.58 | $831.76 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $13,182.57
| Facility | | $4,365.16 | $7,079.46 | $13,182.57 |