- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $3,981.07 / $6,760.83
| Facility | | $524.81 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $512.86 / $1,318.26
| Professional | | $331.13 | $512.86 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $6,025.60 / $12,022.64
| Facility | | $616.60 | $6,025.60 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $831.76 / $1,380.38
| Professional | | $691.83 | $831.76 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $8,912.51 / $53,703.18
| Facility | | $5,495.41 | $8,912.51 | $53,703.18 |