- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,801.89 / $8,128.31
| Facility | | $1,621.81 | $3,801.89 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,348.96 / $3,630.78
| Professional | | $891.25 | $1,348.96 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,174.90 / $3,311.31
| Facility | | $54.95 | $1,174.90 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,202.26 / $3,311.31
| Facility | | $707.95 | $1,202.26 | $3,311.31 |