- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $2,754.23 / $7,079.46
| Facility | | $204.17 | $2,754.23 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $263.03 / $870.96
| Professional | | $144.54 | $263.03 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $2,951.21 / $8,709.64
| Facility | | $263.03 | $2,951.21 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $363.08 / $562.34
| Professional | | $331.13 | $363.08 | $562.34 |
- 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 |