- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,090.30 / $6,309.57
| Facility | | $1,445.44 | $3,090.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $2,238.72 / $4,168.69
| Professional | | $616.60 | $2,238.72 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,778.28 / $2,691.53
| Facility | | $549.54 | $1,778.28 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $794.33 / $2,238.72
| Professional | | $707.95 | $794.33 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,412.54 / $2,238.72
| Facility | | $707.95 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,122.02 / $2,187.76
| Facility | | $199.53 | $1,122.02 | $2,187.76 |