- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.59 / $2,515.60 / $2,515.60
| Facility | | $1,770.59 | $2,515.60 | $2,515.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.82 / $921.82 / $921.82
| Professional | | $921.82 | $921.82 | $921.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.58 / $1,066.58 / $1,066.58
| Facility | | $1,066.58 | $1,066.58 | $1,066.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,043.20 / $2,043.20 / $2,043.20
| Facility | | $2,043.20 | $2,043.20 | $2,043.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.09 / $939.95 / $1,093.20
| Professional | | $666.09 | $939.95 | $1,093.20 |