- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,290.87 / $6,760.83
| Facility | | $398.11 | $2,290.87 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $416.87 / $1,584.89
| Professional | | $275.42 | $416.87 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,071.52 / $13,182.57
| Facility | | $537.03 | $1,071.52 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $812.83 / $1,548.82
| Professional | | $707.95 | $812.83 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,949.84 / $31,622.78
| Facility | | $1,148.15 | $1,949.84 | $31,622.78 |