- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,981.07 / $4,466.84
| Facility | | $3,090.30 | $3,981.07 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Professional | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $831.76
| Professional | | $549.54 | $549.54 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $338.84 / $588.84
| Professional | | $269.15 | $338.84 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $2,454.71
| Facility | | $1,621.81 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $223.87 / $416.87
| Professional | | $112.20 | $223.87 | $416.87 |