- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,011.87 / $7,244.36
| Facility | | $1,584.89 | $5,011.87 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $5,370.32
| Professional | | $138.04 | $138.04 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $562.34 / $1,445.44
| Facility | | $316.23 | $562.34 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,737.80 / $6,165.95
| Facility | | $524.81 | $1,737.80 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,754.23 / $4,265.80
| Facility | | $602.56 | $2,754.23 | $4,265.80 |