- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,168.69 / $6,025.60
| Facility | | $1,698.24 | $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 / $588.84
| Professional | | $30.20 | $44.67 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $512.86 / $1,122.02
| Facility | | $436.52 | $512.86 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | | $562.34 | $562.34 | $562.34 |
- 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 |