- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $5,623.41 / $7,943.28
| Facility | | $295.12 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $380.19
| Professional | | $371.54 | $371.54 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $10,471.29
| Facility | | $7,585.78 | $7,585.78 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $7,413.10 / $19,952.62
| Facility | | $549.54 | $7,413.10 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $11,481.54 / $21,877.62
| Facility | | $8,912.51 | $11,481.54 | $21,877.62 |