- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $4,786.30 / $7,079.46
| Facility | | $354.81 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $218.78 / $2,041.74
| Professional | | $151.36 | $218.78 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $660.69 / $2,137.96
| Facility | | $371.54 | $660.69 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $537.03 / $758.58
| Professional | | $371.54 | $537.03 | $758.58 |
- 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 |