- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,819.70 / $2,511.89
| Facility | | $1,174.90 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $812.83
| Facility | | $588.84 | $588.84 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $831.76 / $1,862.09
| Facility | | $331.13 | $831.76 | $1,862.09 |