- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,290.87 / $6,456.54
| Facility | | $660.69 | $2,290.87 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $933.25 / $1,819.70
| Professional | | $446.68 | $933.25 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,380.38 / $5,370.32
| Facility | | $660.69 | $1,380.38 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $1,995.26
| Professional | | $1,071.52 | $1,479.11 | $1,995.26 |
- 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 |