- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,211.06 / $1,211.06 / $1,845.94
| Facility | | $1,211.06 | $1,211.06 | $1,845.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.02 / $1,211.06 / $1,452.50
| Professional | | $1,019.02 | $1,211.06 | $1,452.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,254.47 / $1,429.54 / $1,557.51
| Facility | | $1,254.47 | $1,429.54 | $1,557.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.34 / $1,384.45 / $1,384.45
| Professional | | $710.34 | $1,384.45 | $1,384.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,343.08 / $1,343.08 / $1,343.08
| Facility | | $1,343.08 | $1,343.08 | $1,343.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.80 / $1,597.98 / $3,316.57
| Professional | | $1,012.80 | $1,597.98 | $3,316.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.24 / $1,252.13 / $1,855.40
| Professional | | $908.24 | $1,252.13 | $1,855.40 |