- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $3,981.07 / $7,244.36
| Facility | | $346.74 | $3,981.07 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $380.19 / $1,621.81
| Professional | | $151.36 | $380.19 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $457.09 / $1,202.26
| Professional | | $186.21 | $457.09 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Facility | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $489.78 / $1,412.54
| Professional | | $162.18 | $489.78 | $1,412.54 |