- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,818.38 / $7,413.10
| Facility | | $1,174.90 | $2,818.38 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $4,897.79
| Professional | | $1,698.24 | $1,698.24 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,677.35 / $8,912.51
| Facility | | $2,238.72 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $575.44 / $1,288.25
| Facility | | $54.95 | $575.44 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $691.83 / $1,380.38
| Facility | | $154.88 | $691.83 | $1,380.38 |