- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,388.44 / $6,760.83
| Facility | | $2,238.72 | $3,388.44 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $147.91 / $5,370.32
| Professional | | $104.71 | $147.91 | $5,370.32 |
- 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
- $4,897.79 / $7,413.10 / $11,481.54
| Facility | | $4,897.79 | $7,413.10 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $10,232.93
| Facility | | $4,365.16 | $6,606.93 | $10,232.93 |