- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.36 / $1,203.92 / $5,942.19
| Facility | | $643.36 | $1,203.92 | $5,942.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,131.09 / $14,936.59 / $20,739.37
| Facility | | $1,131.09 | $14,936.59 | $20,739.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $949.86 / $1,185.13 / $2,370.06
| Facility | | $949.86 | $1,185.13 | $2,370.06 |