- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $6,760.83
| Facility | | $602.56 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $588.84 / $1,318.26
| Professional | | $380.19 | $588.84 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,071.52 / $6,025.60
| Facility | | $512.86 | $1,071.52 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $1,148.15
| Professional | | $794.33 | $933.25 | $1,148.15 |
- 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 |