- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $2,454.71
| Facility | | $1,071.52 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,862.09
| Professional | | $1,047.13 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $302.00
| Facility | | $218.78 | $218.78 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $346.74 / $776.25
| Facility | | $128.82 | $346.74 | $776.25 |