- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $2,511.89 / $6,760.83
| Facility | | $117.49 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $263.03 / $776.25
| Professional | | $87.10 | $263.03 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $416.87 / $2,951.21
| Facility | | $151.36 | $416.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $363.08 / $588.84
| Professional | | $199.53 | $363.08 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,290.87 / $4,897.79
| Facility | | $1,513.56 | $2,290.87 | $4,897.79 |