- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,570.88 / $7,762.47
| Facility | | $1,737.80 | $4,570.88 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $5,888.44
| Facility | | $3,388.44 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,071.52 / $1,621.81
| Professional | | $660.69 | $1,071.52 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,344.23 / $7,244.36
| Facility | | $1,288.25 | $2,344.23 | $7,244.36 |