- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $3,235.94 / $6,760.83
| Facility | | $269.15 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $281.84 / $660.69
| Professional | | $181.97 | $281.84 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $501.19 / $6,025.60
| Facility | | $269.15 | $501.19 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $446.68 / $524.81
| Professional | | $389.05 | $446.68 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $7,413.10
| Facility | | $3,019.95 | $5,370.32 | $7,413.10 |