- 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
- $177.83 / $1,174.90 / $1,995.26
| Professional | | $177.83 | $1,174.90 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,348.96 / $2,290.87
| Facility | | $346.74 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,737.80 / $2,344.23
| Professional | | $389.05 | $1,737.80 | $2,344.23 |
- 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 |