- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $786.81 / $1,071.09 / $3,904.19
| Facility | | $786.81 | $1,071.09 | $3,904.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.36 / $883.30 / $964.95
| Professional | | $445.36 | $883.30 | $964.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.27 / $742.27 / $742.27
| Facility | | $742.27 | $742.27 | $742.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.48 / $5,241.47 / $5,634.47
| Facility | | $482.48 | $5,241.47 | $5,634.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.75 / $445.36 / $927.84
| Professional | | $311.75 | $445.36 | $927.84 |