- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,511.89 / $6,760.83
| Facility | | $501.19 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $457.09 / $1,202.26
| Professional | | $257.04 | $457.09 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,122.02 / $6,606.93
| Facility | | $616.60 | $1,122.02 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $1,202.26
| Professional | | $676.08 | $954.99 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,888.44 / $7,762.47
| Facility | | $3,467.37 | $5,888.44 | $7,762.47 |