- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,102.52 / $1,563.52 / $3,761.25
| Facility | | $1,102.52 | $1,563.52 | $3,761.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.96 / $843.68 / $1,394.71
| Professional | | $670.96 | $843.68 | $1,394.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.13 / $1,429.43 / $2,961.61
| Facility | | $868.13 | $1,429.43 | $2,961.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.32 / $664.32 / $1,220.36
| Professional | | $664.32 | $664.32 | $1,220.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $423.30 / $441.78 / $686.39
| Facility | | $423.30 | $441.78 | $686.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,136.59 / $3,136.59 / $3,136.59
| Professional | | $3,136.59 | $3,136.59 | $3,136.59 |