- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,265.80 / $11,481.54
| Facility | | $2,187.76 | $4,265.80 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $288.40 / $1,412.54
| Professional | | $158.49 | $288.40 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,089.30 / $4,073.80
| Facility | | $1,621.81 | $2,089.30 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $1,230.27 / $4,365.16
| Facility | | $251.19 | $1,230.27 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $1,230.27 / $4,466.84
| Facility | | $251.19 | $1,230.27 | $4,466.84 |