- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $695.16 / $5,463.36 / $7,119.04
| Facility | | $695.16 | $5,463.36 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.98 / $118.05 / $1,207.74
| Professional | | $70.98 | $118.05 | $1,207.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.66 / $202.83 / $2,710.90
| Facility | | $110.66 | $202.83 | $2,710.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.74 / $188.54 / $921.98
| Facility | | $142.74 | $188.54 | $921.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,168.96 / $2,216.52 / $4,745.72
| Facility | | $1,168.96 | $2,216.52 | $4,745.72 |