- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,466.84 / $7,413.10
| Facility | | $2,344.23 | $4,466.84 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $4,570.88
| Professional | | $1,698.24 | $1,698.24 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,238.72 / $3,548.13
| Facility | | $794.33 | $2,238.72 | $3,548.13 |
- 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 |