- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,168.69 / $6,025.60
| Facility | | $3,162.28 | $4,168.69 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $44.67
| Professional | | $30.20 | $44.67 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $407.38 / $870.96
| Facility | | $346.74 | $407.38 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,466.84 / $5,128.61
| Facility | | $1,071.52 | $4,466.84 | $5,128.61 |