- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,659.59 / $2,454.71
| Facility | | $870.96 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $4,570.88
| Facility | | $3,311.31 | $3,311.31 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $302.00
| Professional | | $263.03 | $263.03 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $7,244.36
| Facility | | $1,230.27 | $2,951.21 | $7,244.36 |