- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $3,981.07 / $6,760.83
| Facility | | $501.19 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $549.54 / $1,174.90
| Professional | | $309.03 | $549.54 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $12,302.69 / $28,183.83
| Facility | | $691.83 | $12,302.69 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $891.25 / $1,380.38
| Professional | | $724.44 | $891.25 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,218.10 / $31,622.78
| Facility | | $10,471.29 | $16,218.10 | $31,622.78 |