- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $2,570.40 / $6,760.83
| Facility | | $151.36 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $112.20 / $295.12
| Professional | | $79.43 | $112.20 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $229.09 / $1,905.46
| Facility | | $131.83 | $229.09 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $208.93 / $234.42
| Professional | | $154.88 | $208.93 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,548.13
| Facility | | $1,148.15 | $1,621.81 | $3,548.13 |