- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,388.44 / $4,570.88
| Facility | | $2,951.21 | $3,388.44 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $1,318.26
| Professional | | $588.84 | $588.84 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $323.59 / $758.58
| Facility | | $275.42 | $323.59 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,466.84 / $5,128.61
| Facility | | $1,071.52 | $4,466.84 | $5,128.61 |