- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $3,235.94 / $6,760.83
| Facility | | $93.33 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $114.82 / $275.42
| Professional | | $63.10 | $114.82 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $2,691.53 / $9,332.54
| Facility | | $114.82 | $2,691.53 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $154.88 / $234.42
| Professional | | $138.04 | $154.88 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $9,332.54
| Facility | | $3,162.28 | $5,495.41 | $9,332.54 |