- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $2,511.89 / $6,760.83
| Facility | | $467.74 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $457.09 / $1,288.25
| Professional | | $309.03 | $457.09 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $724.44 / $1,949.84
| Facility | | $426.58 | $724.44 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $794.33 / $891.25
| Professional | | $707.95 | $794.33 | $891.25 |
- 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 |