- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.05 / $972.35 / $1,108.80
| Facility | | $758.05 | $972.35 | $1,108.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.56 / $751.56 / $890.93
| Professional | | $751.56 | $751.56 | $890.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.83 / $2,736.98 / $3,087.43
| Facility | | $180.83 | $2,736.98 | $3,087.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.77 / $477.77 / $477.77
| Professional | | $477.77 | $477.77 | $477.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,849.94 / $1,920.79 / $4,165.21
| Facility | | $1,849.94 | $1,920.79 | $4,165.21 |