- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,570.40 / $6,760.83
| Facility | | $741.31 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $537.03 / $1,202.26
| Professional | | $309.03 | $537.03 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,949.84 / $6,918.31
| Facility | | $616.60 | $1,949.84 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $1,148.15
| Professional | | $645.65 | $912.01 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,128.61 / $7,244.36
| Facility | | $3,019.95 | $5,128.61 | $7,244.36 |