- 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
- $660.69 / $660.69 / $1,380.38
| Professional | | $660.69 | $660.69 | $1,380.38 |
- 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
- $660.69 / $1,905.46 / $4,466.84
| Facility | | $660.69 | $1,905.46 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,041.74 / $4,786.30
| Facility | | $1,258.93 | $2,041.74 | $4,786.30 |