- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,801.89 / $7,943.28
| Facility | | $2,238.72 | $3,801.89 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,862.09 / $2,630.27
| Professional | | $380.19 | $1,862.09 | $2,630.27 |
- 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
- $371.54 / $724.44 / $2,137.96
| Facility | | $371.54 | $724.44 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,202.26 / $2,344.23
| Facility | | $537.03 | $1,202.26 | $2,344.23 |