- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,570.40 / $2,630.27
| Facility | | $398.11 | $2,570.40 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $371.54 / $478.63
| Professional | | $316.23 | $371.54 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $831.76 / $1,047.13
| Professional | | $645.65 | $831.76 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,778.28 / $1,778.28
| Facility | | $630.96 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,148.15 / $1,348.96
| Facility | | $977.24 | $1,148.15 | $1,348.96 |