- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $5,011.87 / $7,943.28
| Facility | | $380.19 | $5,011.87 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $398.11 / $1,548.82
| Professional | | $263.03 | $398.11 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $891.25 / $13,182.57
| Facility | | $562.34 | $891.25 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $741.31 / $1,513.56
| Professional | | $676.08 | $741.31 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,949.84 / $24,547.09
| Facility | | $1,148.15 | $1,949.84 | $24,547.09 |