- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,818.38 / $7,413.10
| Facility | | $1,174.90 | $2,818.38 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $4,897.79
| Professional | | $1,621.81 | $2,398.83 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $380.19 / $467.74
| Professional | | $331.13 | $380.19 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $870.96 / $1,348.96
| Facility | | $245.47 | $870.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,737.80 / $2,951.21
| Facility | | $380.19 | $1,737.80 | $2,951.21 |