- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $4,786.30 / $7,079.46
| Facility | | $512.86 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $371.54 / $1,479.11
| Professional | | $208.93 | $371.54 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $794.33 / $2,137.96
| Facility | | $398.11 | $794.33 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $724.44 / $831.76
| Professional | | $588.84 | $724.44 | $831.76 |
- 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 |