- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,570.40 / $6,760.83
| Facility | | $1,698.24 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $524.81 / $4,570.88
| Professional | | $162.18 | $524.81 | $4,570.88 |
- 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
- $1,348.96 / $2,570.40 / $5,888.44
| Facility | | $1,348.96 | $2,570.40 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,162.28 / $6,309.57
| Facility | | $1,412.54 | $3,162.28 | $6,309.57 |