- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $3,981.07 / $6,760.83
| Facility | | $512.86 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $457.09 / $1,148.15
| Professional | | $281.84 | $457.09 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $870.96 / $5,370.32
| Facility | | $512.86 | $870.96 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $741.31 / $891.25
| Professional | | $630.96 | $741.31 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,248.07 / $7,413.10
| Facility | | $2,951.21 | $5,248.07 | $7,413.10 |