- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,570.40 / $6,760.83
| Facility | | $100.00 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $91.20 / $309.03
| Professional | | $63.10 | $91.20 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.62 / $134.90 / $1,778.28
| Facility | | $77.62 | $134.90 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $147.91 / $173.78
| Professional | | $107.15 | $147.91 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,548.13
| Facility | | $1,148.15 | $1,621.81 | $3,548.13 |