- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $15,848.93 / $15,848.93
| Facility | | $2,290.87 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $8,912.51 / $8,912.51
| Professional | | $380.19 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |