- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,570.40 / $6,760.83
| Facility | | $645.65 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $575.44 / $1,412.54
| Professional | | $346.74 | $575.44 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,047.13 / $7,079.46
| Facility | | $537.03 | $1,047.13 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $912.01 / $1,071.52
| Professional | | $758.58 | $912.01 | $1,071.52 |
- 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 |