- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,145.06 / $1,523.52 / $1,909.92
| Facility | | $1,145.06 | $1,523.52 | $1,909.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.06 / $1,145.06 / $1,409.05
| Professional | | $1,145.06 | $1,145.06 | $1,409.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.18 / $585.78 / $848.51
| Facility | | $436.18 | $585.78 | $848.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.86 / $520.86 / $520.86
| Professional | | $520.86 | $520.86 | $520.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,145.06 / $1,145.06 / $1,316.82
| Facility | | $1,145.06 | $1,145.06 | $1,316.82 |