- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.27 / $1,185.27 / $1,185.27
| Facility | | $1,185.27 | $1,185.27 | $1,185.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.67 / $970.05 / $1,317.02
| Professional | | $764.67 | $970.05 | $1,317.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.74 / $1,053.86 / $1,164.72
| Facility | | $867.74 | $1,053.86 | $1,164.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.72 / $931.44 / $931.44
| Professional | | $791.72 | $931.44 | $931.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,224.34 / $2,224.34 / $2,224.34
| Facility | | $2,224.34 | $2,224.34 | $2,224.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.82 / $956.97 / $1,915.44
| Professional | | $802.82 | $956.97 | $1,915.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.33 / $850.63 / $1,366.61
| Professional | | $461.33 | $850.63 | $1,366.61 |