- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,513.56
| Professional | | $1,202.26 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,348.96 / $1,995.26
| Facility | | $416.87 | $1,348.96 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,318.26 / $2,238.72
| Facility | | $794.33 | $1,318.26 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,412.54 / $2,187.76
| Facility | | $691.83 | $1,412.54 | $2,187.76 |