- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,801.89 / $20,892.96
| Facility | | $1,230.27 | $3,801.89 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $1,548.82
| Professional | | $630.96 | $630.96 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,621.81 / $24,547.09
| Facility | | $977.24 | $1,621.81 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $24,547.09
| Facility | | $1,148.15 | $1,819.70 | $24,547.09 |