- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $2,511.89 / $6,760.83
| Facility | | $223.87 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $794.33 / $1,621.81
| Professional | | $151.36 | $794.33 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,122.02 / $2,187.76
| Facility | | $295.12 | $1,122.02 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $933.25 / $1,698.24
| Professional | | $363.08 | $933.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $4,897.79
| Facility | | $1,288.25 | $2,290.87 | $4,897.79 |