- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $7,943.28
| Facility | | $4,265.80 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Professional | | $269.15 | $269.15 | $269.15 |
- 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
- $467.74 / $891.25 / $2,137.96
| Facility | | $467.74 | $891.25 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,202.26 / $2,344.23
| Facility | | $588.84 | $1,202.26 | $2,344.23 |