- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $2,511.89 / $6,760.83
| Facility | | $218.78 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $309.03 / $616.60
| Professional | | $151.36 | $309.03 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $537.03 / $2,290.87
| Facility | | $251.19 | $537.03 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $562.34 / $724.44
| Professional | | $371.54 | $562.34 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,344.23 / $4,897.79
| Facility | | $1,548.82 | $2,344.23 | $4,897.79 |