- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,090.30 / $6,760.83
| Facility | | $602.56 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $398.11 / $1,584.89
| Professional | | $263.03 | $398.11 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $724.44 / $6,025.60
| Facility | | $389.05 | $724.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $676.08 / $724.44
| Professional | | $602.56 | $676.08 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $7,413.10
| Facility | | $3,019.95 | $5,370.32 | $7,413.10 |