- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $6,918.31 / $7,244.36
| Facility | | $1,778.28 | $6,918.31 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $2,137.96
| Professional | | $724.44 | $1,023.29 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,445.44
| Professional | | $758.58 | $1,023.29 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $933.25 / $1,412.54
| Professional | | $707.95 | $933.25 | $1,412.54 |