- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,162.28 / $4,570.88
| Facility | | $1,698.24 | $3,162.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $331.13 / $758.58
| Facility | | $281.84 | $331.13 | $758.58 |
- 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 |