- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $2,290.87 / $6,456.54
| Facility | | $426.58 | $2,290.87 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $426.58 / $1,122.02
| Professional | | $199.53 | $426.58 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $724.44 / $6,918.31
| Facility | | $338.84 | $724.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $776.25 / $977.24
| Professional | | $478.63 | $776.25 | $977.24 |
- 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 |