- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $2,511.89 / $6,760.83
| Facility | | $263.03 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $1,047.13 / $1,698.24
| Professional | | $158.49 | $1,047.13 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,548.82 / $2,344.23
| Facility | | $398.11 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $2,041.74 / $2,398.83
| Professional | | $416.87 | $2,041.74 | $2,398.83 |
- 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 |