- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,981.07 / $7,943.28
| Facility | | $602.56 | $3,981.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $524.81 / $1,096.48
| Professional | | $338.84 | $524.81 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $14,125.38 / $51,286.14
| Facility | | $660.69 | $14,125.38 | $51,286.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $891.25 / $1,412.54
| Professional | | $794.33 | $891.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $19,054.61 / $51,286.14
| Facility | | $10,471.29 | $19,054.61 | $51,286.14 |