- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $5,370.32 / $7,943.28
| Facility | | $389.05 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $407.38 / $912.01
| Professional | | $218.78 | $407.38 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $524.81 / $5,623.41
| Facility | | $251.19 | $524.81 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $537.03 / $645.65
| Professional | | $446.68 | $537.03 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $7,413.10 / $11,748.98
| Facility | | $1,778.28 | $7,413.10 | $11,748.98 |