- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.42 / $1,005.80 / $1,830.18
| Facility | | $510.42 | $1,005.80 | $1,830.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.02 / $693.71 / $848.84
| Professional | | $419.02 | $693.71 | $848.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $885.45 / $885.45 / $885.45
| Facility | | $885.45 | $885.45 | $885.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,702.87 / $3,702.87 / $3,702.87
| Professional | | $3,702.87 | $3,702.87 | $3,702.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $424.96 / $424.96 / $1,112.02
| Facility | | $424.96 | $424.96 | $1,112.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.74 / $883.24 / $1,279.20
| Professional | | $856.74 | $883.24 | $1,279.20 |