- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $2,570.40 / $6,760.83
| Facility | | $165.96 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $181.97 / $407.38
| Professional | | $95.50 | $181.97 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $190.55 / $1,288.25
| Facility | | $102.33 | $190.55 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $234.42 / $275.42
| Professional | | $190.55 | $234.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $3,548.13
| Facility | | $1,023.29 | $1,621.81 | $3,548.13 |