- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $4,570.88 / $7,079.46
| Facility | | $645.65 | $4,570.88 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $912.01 / $2,344.23
| Professional | | $398.11 | $912.01 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,380.38 / $9,549.93
| Facility | | $676.08 | $1,380.38 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,174.90 / $1,584.89
| Professional | | $954.99 | $1,174.90 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $10,232.93
| Facility | | $4,365.16 | $6,606.93 | $10,232.93 |