- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.05 / $1,112.46 / $1,112.46
| Facility | | $927.05 | $1,112.46 | $1,112.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.23 / $630.39 / $630.39
| Professional | | $556.23 | $630.39 | $630.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.21 / $4,171.72 / $20,024.28
| Facility | | $1,001.21 | $4,171.72 | $20,024.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.97 / $1,001.21 / $119,998.80
| Professional | | $889.97 | $1,001.21 | $119,998.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.49 / $370.82 / $1,075.38
| Professional | | $311.49 | $370.82 | $1,075.38 |