- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $446.68 / $933.25
| Professional | | $251.19 | $446.68 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,258.93 / $1,513.56
| Facility | | $416.87 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,995.26 / $4,786.30
| Facility | | $602.56 | $1,995.26 | $4,786.30 |