- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $3,235.94 / $6,760.83
| Facility | | $354.81 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $426.58 / $776.25
| Professional | | $239.88 | $426.58 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $1,819.70 / $6,606.93
| Facility | | $426.58 | $1,819.70 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $575.44 / $870.96
| Professional | | $524.81 | $575.44 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $7,413.10
| Facility | | $3,019.95 | $5,370.32 | $7,413.10 |