- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $3,981.07 / $6,760.83
| Facility | | $512.86 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $478.63 / $954.99
| Professional | | $309.03 | $478.63 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $12,022.64 / $25,118.86
| Facility | | $602.56 | $12,022.64 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $812.83 / $1,288.25
| Professional | | $724.44 | $812.83 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,218.10 / $26,302.68
| Facility | | $10,471.29 | $16,218.10 | $26,302.68 |