- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,683.47 / $1,683.47 / $2,324.80
| Facility | | $1,683.47 | $1,683.47 | $2,324.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.65 / $1,296.01 / $1,683.47
| Professional | | $801.65 | $1,296.01 | $1,683.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.46 / $1,007.41 / $2,396.94
| Facility | | $868.46 | $1,007.41 | $2,396.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.48 / $1,202.48 / $1,336.09
| Facility | | $1,202.48 | $1,202.48 | $1,336.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $801.65 / $1,336.09
| Professional | | $561.16 | $801.65 | $1,336.09 |