- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,011.87 / $7,413.10
| Facility | | $2,884.03 | $5,011.87 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $812.83 / $5,011.87
| Professional | | $186.21 | $812.83 | $5,011.87 |
- 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
- $213.80 / $1,513.56 / $2,511.89
| Facility | | $213.80 | $1,513.56 | $2,511.89 |