- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $3,090.30 / $6,760.83
| Facility | | $144.54 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $257.04 / $501.19
| Professional | | $89.13 | $257.04 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $389.05 / $4,677.35
| Facility | | $144.54 | $389.05 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $346.74 / $588.84
| Professional | | $208.93 | $346.74 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $6,309.57
| Facility | | $2,570.40 | $4,677.35 | $6,309.57 |