- 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
- $147.91 / $724.44 / $5,128.61
| Professional | | $147.91 | $724.44 | $5,128.61 |
- 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 / $2,511.89 / $5,888.44
| Facility | | $1,348.96 | $2,511.89 | $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 |