- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $4,073.80 / $8,511.38
| Facility | | $616.60 | $4,073.80 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $426.58 / $549.54
| Professional | | $251.19 | $426.58 | $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 / $11,220.18
| Facility | | $724.44 | $1,288.25 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $602.56 / $1,047.13
| Facility | | $489.78 | $602.56 | $1,047.13 |