- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $2,511.89
| Facility | | $1,288.25 | $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
- $512.86 / $562.34 / $562.34
| Facility | | $512.86 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $371.54 / $549.54
| Professional | | $331.13 | $371.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $758.58 / $2,570.40
| Facility | | $371.54 | $758.58 | $2,570.40 |