- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $3,981.07
| Facility | | $2,344.23 | $3,467.37 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,513.56
| Professional | | $1,096.48 | $1,096.48 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $10,471.29 / $12,589.25
| Facility | | $5,754.40 | $10,471.29 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,025.60 / $12,589.25
| Facility | | $1,230.27 | $6,025.60 | $12,589.25 |