- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,388.44 / $6,760.83
| Facility | | $1,862.09 | $3,388.44 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $316.23 / $1,258.93
| Professional | | $158.49 | $316.23 | $1,258.93 |
- 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
- $288.40 / $549.54 / $1,949.84
| Facility | | $288.40 | $549.54 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,202.26 / $2,344.23
| Facility | | $436.52 | $1,202.26 | $2,344.23 |