- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $3,235.94 / $6,760.83
| Facility | | $512.86 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $562.34 / $1,023.29
| Professional | | $309.03 | $562.34 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $2,630.27 / $5,888.44
| Facility | | $630.96 | $2,630.27 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $851.14 / $1,258.93
| Professional | | $741.31 | $851.14 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,011.87 / $6,760.83
| Facility | | $2,691.53 | $5,011.87 | $6,760.83 |