- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $7,244.36
| Facility | | $4,073.80 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $398.11 / $870.96
| Professional | | $162.18 | $398.11 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $295.12 / $676.08
| Professional | | $158.49 | $295.12 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $316.23 / $741.31
| Professional | | $154.88 | $316.23 | $741.31 |