- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $2,570.40 / $6,760.83
| Facility | | $309.03 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $275.42 / $933.25
| Professional | | $177.83 | $275.42 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $512.86 / $5,128.61
| Facility | | $288.40 | $512.86 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $446.68 / $524.81
| Professional | | $389.05 | $446.68 | $524.81 |
- 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 |