- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $5,370.32 / $7,943.28
| Facility | | $467.74 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $478.63 / $870.96
| Professional | | $288.40 | $478.63 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $831.76 / $2,344.23
| Facility | | $512.86 | $831.76 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $831.76 / $1,230.27
| Professional | | $676.08 | $831.76 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,548.13
| Facility | | $1,148.15 | $1,621.81 | $3,548.13 |