- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,318.26 / $4,168.69
| Facility | | $501.19 | $1,318.26 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $1,548.82
| Professional | | $630.96 | $630.96 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $14,454.40 / $37,153.52
| Facility | | $0.02 | $14,454.40 | $37,153.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $8,912.51 / $20,892.96
| Facility | | $5,623.41 | $8,912.51 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $512.86 / $1,995.26
| Facility | | $208.93 | $512.86 | $1,995.26 |