- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $2,570.40 / $6,760.83
| Facility | | $436.52 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $426.58 / $1,995.26
| Professional | | $263.03 | $426.58 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $831.76 / $30,199.52
| Facility | | $426.58 | $831.76 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $741.31 / $831.76
| Professional | | $575.44 | $741.31 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,218.10 / $30,199.52
| Facility | | $10,471.29 | $16,218.10 | $30,199.52 |