- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,511.89 / $6,760.83
| Facility | | $398.11 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $524.81 / $1,047.13
| Professional | | $234.42 | $524.81 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $812.83 / $6,918.31
| Facility | | $398.11 | $812.83 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $776.25 / $1,202.26
| Professional | | $562.34 | $776.25 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,309.57 / $8,912.51
| Facility | | $4,168.69 | $6,309.57 | $8,912.51 |