- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $980.55 / $1,644.74 / $3,956.64
| Facility | | $980.55 | $1,644.74 | $3,956.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.50 / $658.26 / $913.28
| Professional | | $523.50 | $658.26 | $913.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.91 / $1,503.68 / $3,115.46
| Facility | | $898.91 | $1,503.68 | $3,115.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.32 / $518.32 / $819.26
| Professional | | $518.32 | $518.32 | $819.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $824.60 / $824.60 / $1,803.64
| Facility | | $824.60 | $824.60 | $1,803.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.09 / $2,254.55 / $2,254.55
| Professional | | $541.09 | $2,254.55 | $2,254.55 |