- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,168.69 / $7,413.10
| Facility | | $1,905.46 | $4,168.69 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $1,513.56 / $5,370.32
| Professional | | $162.18 | $1,513.56 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,467.37 / $7,585.78
| Facility | | $794.33 | $3,467.37 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,168.69 / $6,918.31
| Facility | | $1,202.26 | $4,168.69 | $6,918.31 |