- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $2,344.23 / $4,786.30
| Facility | | $616.60 | $2,344.23 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $371.54 / $549.54
| Professional | | $316.23 | $371.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,023.29 / $1,659.59
| Facility | | $562.34 | $1,023.29 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,288.25 / $10,232.93
| Facility | | $724.44 | $1,288.25 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $602.56 / $1,047.13
| Facility | | $489.78 | $602.56 | $1,047.13 |