- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.27 / $1,548.67 / $1,717.93
| Facility | | $846.27 | $1,548.67 | $1,717.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.55 / $1,548.67 / $1,717.93
| Professional | | $668.55 | $1,548.67 | $1,717.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.08 / $1,255.08 / $1,255.08
| Facility | | $1,255.08 | $1,255.08 | $1,255.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.08 / $1,255.08 / $1,255.08
| Professional | | $1,255.08 | $1,255.08 | $1,255.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.54 / $577.58 / $941.03
| Facility | | $512.54 | $577.58 | $941.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.22 / $385.35 / $1,448.87
| Professional | | $362.22 | $385.35 | $1,448.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $507.76 / $1,438.66
| Professional | | $355.43 | $507.76 | $1,438.66 |