- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,298.30 / $6,262.52 / $17,050.91
| Facility | | $2,298.30 | $6,262.52 | $17,050.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $402.32
| Professional | | $402.32 | $402.32 | $402.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.42 / $104.42 / $104.42
| Facility | | $104.42 | $104.42 | $104.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,353.81
| Professional | | $1,054.93 | $1,054.93 | $1,353.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,839.75 / $2,053.23 / $12,458.38
| Facility | | $1,839.75 | $2,053.23 | $12,458.38 |