- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $3,801.89 / $6,456.54
| Facility | | $295.12 | $3,801.89 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $363.08 / $758.58
| Professional | | $141.25 | $363.08 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $549.54 / $6,456.54
| Facility | | $234.42 | $549.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $467.74 / $831.76
| Professional | | $346.74 | $467.74 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $7,762.47
| Facility | | $3,162.28 | $5,495.41 | $7,762.47 |