- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,151.38 / $1,227.04 / $1,227.04
| Facility | | $1,151.38 | $1,227.04 | $1,227.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,303.44
| Professional | | $1,227.04 | $1,227.04 | $1,303.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.35 / $1,648.48 / $3,094.62
| Facility | | $1,216.35 | $1,648.48 | $3,094.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $2,041.79 / $2,331.38
| Facility | | $1,227.04 | $2,041.79 | $2,331.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.97 / $615.97 / $652.17
| Facility | | $615.97 | $615.97 | $652.17 |