- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $3,090.30 / $6,456.54
| Facility | | $512.86 | $3,090.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $489.78 / $891.25
| Professional | | $239.88 | $489.78 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $891.25 / $7,079.46
| Facility | | $416.87 | $891.25 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $724.44 / $1,071.52
| Professional | | $588.84 | $724.44 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,309.57 / $8,912.51
| Facility | | $3,801.89 | $6,309.57 | $8,912.51 |