- 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
- $1,412.54 / $1,412.54 / $4,168.69
| Professional | | $1,412.54 | $1,412.54 | $4,168.69 |
- 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
- $338.84 / $630.96 / $1,949.84
| Facility | | $338.84 | $630.96 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,202.26 / $2,344.23
| Facility | | $512.86 | $1,202.26 | $2,344.23 |