- 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
- $588.84 / $1,698.24 / $1,778.28
| Professional | | $588.84 | $1,698.24 | $1,778.28 |
- 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 / $2,137.96
| Facility | | $288.40 | $549.54 | $2,137.96 |
- 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 |