- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $6,760.83 / $8,317.64
| Facility | | $190.55 | $6,760.83 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $912.01
| Professional | | $120.23 | $199.53 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $537.03 / $6,606.93
| Facility | | $275.42 | $537.03 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $338.84 / $1,096.48
| Professional | | $275.42 | $338.84 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |