- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,388.44 / $6,760.83
| Facility | | $2,818.38 | $3,388.44 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $3,801.89 / $3,981.07
| Professional | | $812.83 | $3,801.89 | $3,981.07 |
- 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
- $354.81 / $660.69 / $2,137.96
| Facility | | $354.81 | $660.69 | $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 |