- 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
- $1,023.29 / $1,202.26 / $2,754.23
| Facility | | $1,023.29 | $1,202.26 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,818.38 / $5,128.61
| Facility | | $1,096.48 | $2,818.38 | $5,128.61 |